TAKE THE QUIZ

Name *

First Name

Last Name

Phone

(Only if you'd like a call-back.)

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Do you experience any of the following?

Check as many as you like.

Clinical Depression

Generalized Anxiety

Chronic Allergies

Early Signs of Alzheimer's

Early Signs of Dementia

Aggression

Attention Deficit Disorder

What about your cardiovascular health?

Check as many as you like.

Hypertension

Heart Disease

Chronic Fatigue

Heart Palpitations

Cardiovascular Disease

Do you have any symptoms of an unhealthy body?

Check all that apply.

Snoring

Cancer

Obesity

Mouth Breathing

Hypothyroidism

Headaches

Diabetes

Fibromyalgia

Chronic Pain

Do you experience any of the following during sleep?

Choose all that apply.

Snoring

Gasping Episodes

Choking or Coughing

Restless Sleep

Restless Leg Syndrome

Insomnia

During the day, do you experience any of the following?

Chronic Fatique

Persistent Yawning

Sleepiness

Chronic Pain

Soreness in Hands

Soreness in Feet

What about your oral health?

Select any that applies to you.

I have had my wisdom teeth extracted

I have had other adult teeth extracted

I wore braces to straighten teeth

I probably should have worn braces

I have had my tonsils removed

I have had my adenoids removed

Have you been diagnosed with mild-to-moderate obstructive sleep apnea?

Yes

No

Has anyone ever told you that you stop breathing while you sleep?

Yes

No

Do you take medication for the following?

Check all that apply.

Hypertension

Depression

Anxiety

Gastric Reflux

Heart Disease

ADHD

Chronic Pain

Have you ever taken a home sleep study?

Yes

No

Has a doctor ever prescribed the use of a CPAP machine?

Yes

No

Have you ever heard of Maxillo-Mandibular Hypoplasia?

Maxillo-Mandibular Hypoplasia or underdeveloped upper and lower jaws is a common condition that affects millions of people of all ages world-wide. In 97 percent of cases of Obstructive Sleep Apnea, the underlying cause is Maxillo-Mandibular Hypoplasia.

Yes

No