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Stop-Bang Questionnaire
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Stop-Bang Questionnaire
Have you been told you snore loudly (louder than talking or loud enough to be heard through closed doors?
(Required)
Yes
No
Do you often feel tired during the daytime?
(Required)
Yes
No
Has anyone ever observed you stop breathing while sleeping?
(Required)
Yes
No
Do you have or are you being treated for high blood pressure?
(Required)
Yes
No
Medication?
How old are you?
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Neck circumference greater than 40 cm/16 inches?
Are You Interested in a FREE Consultation?
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No
Name
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Last
Phone
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Email
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Stop-Bang Questionnaire
Name
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First
Last
Phone
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Email
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Gender
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Male
Female
Other
Date of Birth
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DD slash MM slash YYYY
Office Location
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Dental Now Panorama
Quarry Park Dental
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Height
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Weight
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BMI
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Snoring
Sleep Apnea
Sleep Assessment​
Forms & Resources
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Expand
Patient Care
Pre-Treatment Sleep Questionnaire
New Patient Form
Insurance Package
