Assess Your Risk of Sleep Apnea
Sign in to Google to save your progress. Learn more
Email *
Full name as per IC *
Age *
Mobile Number (012-3456788) *
Do you SNORE loudly (louder than talking or loud enough to be heard through closed doors)? *
Do you often feel TIRED, fatigued, or sleepy during daytime? *
Has anyone OBSERVED you stop breathing during your sleep? *
Do you have or are you being treated for high blood PRESSURE? *
BMI > 28kg/m2? *
Age > 50 years old? *
Neck circumference > 38cm? *
Male GENDER? *
I hereby declare that the details furnished above are true and correct to the best of my knowledge and belief and I undertake the responsibility to inform you of any changes therein, immediately.
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Bespoke Health Sdn Bhd. Report Abuse