Patient Name: *

First Name

Last Name

Patient Phone Number: *

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Symptoms: *

Check any that are applicable.

Excessive daytime sleepiness

Drinks multiple caffeinated drinks a day

Inability to sleep through the night

Morning headaches

Anxiety

Clenching and grinding

Memory/Concentration difficulties

Snoring

Waking up frequently at night to go to the bathroom

Irritability

Previous Diagnosis of OSA

Currently uses CPAP

Other

Provider Office Number: *

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Office Fax Number: (Optional)

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