Date MM slash DD slash YYYY Name First Last Date of Birth MM slash DD slash YYYY Why are we asking about your sleep?Sleep Apnea May increase your blood pressure May increase your risk for atrial fibrillation May increase your risk of stroke May increase the risk of diabetes and obesity. Do you snore loudly? Yes No Do often feel tired or sleepy during the daytime? Yes No Have you noticed or been told that you stop breathing or choke during sleep? Yes No Do you have or are yo ucurrently being treated for high blood pressure? Yes No Are you male? Yes No Are you 50 years or older? Yes No HEIGHTWEIGHTCAPTCHA Δ
