Home Sleep Apnea Test - Intake Form - Snore MD

Are you currently prescribed/using opioid medications for a sustained period greater than 6 months? (Note: Marijuana and post surgery treatment is excluded)

Have you had a Stroke within the last 12 months?

Have you had Consistent Irregular Heartbeats diagnosed by a Medical Doctor within the last 12 months?

Are you wheelchair bound?

Do you have ALS (Lou Gehrig’s) or any other Neuromuscular Condition?

Do you have uncontrolled Congestive Heart Failure (CHF)?

Do you have significant/severe COPD or Pulmonary Fibrosis (such that it impacts your quality of life) example, unable to walk a flight of stairs without pausing?

In the last 5 years, have you ever slept in a hospital sleep lab and been diagnosed with insomnia by a doctor following that hospital sleep test?

Are you currently on Kidney Dialysis with more than one treatment session per week?

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Please complete the questions below ASAP

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