Am I a Candidate?

Complete a simple online self-assessment.

Order Number

First Name

Last Name

Phone #

Patient's Date of Birth *

Gender *

Male Female

Have you ever had a sleep test administered?

Yes No

If yes - when did you have your last sleep test?

Have you been diagnosed with Sleep Apnea?

Yes No

Do you currently use a CPAP or Sleep Appliance for Sleep Apnea?

Yes No

Are you happy with your CPAP or Sleep Appliance?

Yes No

If you are not happy - why?

How often do you get out of bed to use the restroom during the night?

Do you usually wake feeling tired and unrested?

Yes No

Do you habitually snore?

Yes No

Have you been diagnosed with Hypertension/High Blood Pressure?

Yes No

Do you often suffer from waking headaches?

Yes No

Do you regularly experience daytime drowsiness or fatigue?

Yes No

Do you have blocked nasal passages?

Yes No

Has anyone observed you stop breathing during your sleep?

Yes No

Do you ever wake up choking or gasping?

Yes No

Do you grind your teeth while sleeping?

Yes No

Is your neck circumference greater than 40 cm/ 15.75

Yes No

Is your Body Mass Index (BMI) more than 35?

Yes No Not Sure

I acknowledge that this self-assessment is not designed to diagnose, treat, prevent or cure any health condition and is for information only. *

Yes

Schedule A Consultation

Contact us now to schedule a complimentary consultation to learn more about the symptoms and causes of sleep and breathing disorders and how Watsonville Sleep & Breathing Center can help.

CALL TODAY (831) 728-2266

Or use the form to send us an email.

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About Us

WSBC treats people of all ages with a proprietary, non-invasive, nonsurgical treatment option for the treatment of mild to moderate sleep apnea, snoring and sleep disordered breathing.

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Contact Info

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Phone

(831) 319-4344

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Address

36 Aspen Way, Suite B
Watsonville, CA 95076

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Contact us now to schedule a complimentary consultation to learn more about the symptoms and causes of sleep and breathing disorders.

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