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Patient Health History
Personal & Family Health History
Please list other conditions experienced by you or your family
YesNo
Have you ever been tested for sleep apnea?
Do you snore loudly?
Do you ever wake up through the night gasping for air?
Has anyone ever told you that you that you stop breathing while asleep?
Are you being treated for high blood pressure?
Do you have daytime sleepiness or dozing off at inappropriate times?
Do have headaches upon awakening in the morning?
Do you feel unrested in the morning when you awaken?
Gynecologic History