VitalSleep® is a Class II medical
device . To determine if VitalSleep is suitable for you, please answer the following confidential 14 health questions.
It is not suitable for people with certain conditions. This product is only to be used to treat simple snoring and is not to be used if you have central
sleep apnea , which is not the same as the more common obstructive sleep apnea. To determine if VitalSleep is right for you, please complete the following health questionnaire.
1.
Are you at least 18 years old? *
2.
Are you the intended user of VitalSleep? Only the intended user may order. *
3.
Have you been diagnosed with temporal mandibular disorder, also known as TMJ or TMD? *
4.
Are you getting orthodontic treatments, wear braces, or have dental implants less than 1 year old? *
5.
Do you have abscesses, loose teeth, gum disease or any conditions of the jaw? *
6.
Does your jaw ever lock in an open or closed position? *
7.
Do you have gingivitis, chronic emphysema, severe asthma or any other respiratory disorder? *
8.
Do you have pain in your teeth or and/or difficulty with chewing or swallowing? *
9.
Have you had any jaw injury or jaw surgery within the past 5 years? *
10.
Do you have frequent headaches and/or pain in your temples? *
11.
Does your jaw make popping, clicking or grating noise? *
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.
Do you agree to the Terms & Conditions *
