(971) 339-0816 Portland

Home
About
Services
Signs and Symptoms
Technology
- Back
- DEKA Laser
Referring Providers
Request an Appointment

Request An Appointment

Select a Day

Mon

Tue

Wed

Thu

Fri

Sat

Sun

Please Select Day

Select a Time

Morning

Afternoon

Evening

New Patient? Yes No

Please Select Time

Please fill all the fields.

Great.

Something went wrong

Sleep Quiz

Home
sleep quiz

sleep health partners

GREAT SLEEP IS OUR VISION

Sleep Health Partners Sleep Quiz

About 70 million Americans experience persistent sleep issues. Can you be counted among them? One of the reasons could be the busy schedule that prevents you from getting adequate sleep. However, you may occasionally suffer from excessive tiredness and a lack of energy as a result of a sleep condition, such as obstructive sleep apnea (OSA). According to studies, 80% of instances of moderate-to-severe OSA haven't even been diagnosed. If OSA is not treated, it can drastically reduce your lifespan by decades. Take this quick short quiz to determine your risk for obstructive sleep apnea.

Have you been told that you snore?*
- Yes
- No
Have you been told that you stop breathing while you sleep, even though you don't remember doing so when you wake up?*
- Yes
- No
Do you have high blood pressure?*
- Yes
- No
Do you get morning headaches?*
- Yes
- No
Do you sweat excessively at night?*
- Yes
- No
Are you overweight?*
- Yes
- No
Do you feel sleepy throughout the day even if you slept through the night?*
- Yes
- No
Do you have trouble at work due to sleepiness?*
- Yes
- No
Do you wake up suddenly during the night, gasping for breath?*
- Yes
- No
Do you have trouble sleeping when you have a cold?*
- Yes
- No

Your Information

Name*

First Last

Date of Birth*

Address*

Street AddressAddress Line 2City
State / Province / RegionZIP / Postal Code

Phone Number*

Email*

Are You a New Patient?*

Yes
No

Primary Medical Insurance Information
Name of Company*
Member or Subscriber ID*
Group #*
Provider Services Phone Number*
Referred By
Have you previously been treated by Sleep Medicine Group / Dr. Zelk?*
- Yes
- No
Approximate age of current oral appliance
Additional Information
Preferred Day of the Week?*
- Select All
- Monday
- Tuesday
- Wednesday
- Thursday
- Friday
What time of day do you prefer (Mornings or Afternoons)?*
Would You Briefly Describe Your Situation? (Optional)

Form Submitted Successfully

Phone: (971) 339-0816

Email: [email protected]

Address:

9370 SW Greenburg Rd, Suite 422 Rd Suite 422, Portland, 97223

Working Hours

MON9:30 am-5:00 pm
TUEClosed
WED9:30 am-5:00 pm
THUClosed
FRI9:30 am-5:00 pm
SAT - SUNClosed

Portland

9370 SW Greenburg Rd, Suite 422 Rd Suite 422, Portland 97223

(971) 339-0816
[email protected]

© Copyright 2023 GrowthPlug, Inc
Privacy Policy
Terms and Conditions
Accessibility Statement