Health Questionnaire

VitalSleep is a Class II medical device that has been cleared by the FDA. It is not suitable for people with certain conditions. The Snore Reliever Company is not liable for any damages or injuries resulting from false or erroneous information provided by you. This product is for treating snoring and is not to be used if you have central sleep apnea. This is not the same as the more common obstructive sleep apnea. Please complete the health questionnaire.

* Answer all questions.
1.
Are you at least 18 years old? *
Yes
No
2.
Are you the intended user of VitalSleep? Only the intended user may order. *
Yes
No
3.
Have you been diagnosed with temporal mandibular disorder, also known as TMJ or TMD? *
No
Yes
4.
Are you presently undergoing orthodontic treatments or do you wear braces? *
No
Yes
5.
Do you have abscesses, loose teeth, gum disease or wear full dentures? *
No
Yes
6.
Does your jaw ever lock in an open or closed position? *
No
Yes
7.
Do you have gingivitis, chronic emphysema, asthma or any other respiratory disorder? *
No
Yes
8.
Do you have pain in your teeth or and/or difficulty with chewing or swallowing? *
No
Yes
9.
Have you had any jaw injury or jaw surgery within the past 5 years? *
No
Yes
10.
Do you have frequent headaches and/or pain in your temples? *
No
Yes
11.
Does your jaw make popping, clicking or grating noise? *
No
A little
A lot
12.
Do you have discomfort or pain when you open or close your mouth? *
No pain at all
A little pain
A lot of pain
13.
Do you have pain or ringing in your ears? *
No pain or ringing
A little pain and/or ringing
A lot of pain and/or ringing
14.
I agree to the Terms and Conditions? Terms & Conditions *
Yes
No