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Have you been told that you snore excessively, or that your breathing is interrupted while you sleep?
Do you feel sleepy or fatigued during the day?
Do you doze off while reading, watching television or driving?
Do your legs jerk frequently or feel uncomfortable (restless) before or during sleep?
Do you have trouble falling asleep?
Do you awake with a headache?
Do you experience memory loss?
Do you awake gasping for air?
Do you find your heart beating irregularly at night?
Do you awake in the morning without feeling refreshed?
Do you ever experience sleep paralysis?
Do you have a weight problem?
Is your work or family life affected by your sleep problems?
Do you feel that you get less sleep than you need at night?

If you checked two or more of these questions, seek more information about sleep disorders from the Bay Sleep Clinic or your own physician.

   Do you want us to contact you?        If so, please provide:

First Name:        Last Name:   

Height: ft  inc        Weight  lb     Neck Size     Male    Female

What type of insurance do you have?  Company Plan     Individual Plan         None

Insurance company name:     PPO     HMO     Medicare

Area code:   Phone:         eMail:     

How did you hear about Bay Sleep Clinic?