Vital Sleep

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Health Questionnaire

As an FDA cleared anti-snoring device, VitalSleep is ideal for users not suffering from more complicated medical issues. Your safety and well being is important to us, so please take a moment to complete a confidential health questionnaire to help determine if VitalSleep is suitable for you.

This product is to be used to treat 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.
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 TMJ?*
Also known as TMD or Temporalmandibular Disorder and occurs as a result of problems with the jaw joint and facial muscles that control jaw movement.
    
4.
Are you getting orthodontic treatments, wear braces, or have dental implants less than 1 year old? *
    
5.
Do you have any infections of the teeth or gums, loose teeth, or any conditions of the jaw? *
    
6.
Does your jaw ever lock in an open or closed position? *
    
7.
Do you have gum disease, chronic emphysema, severe asthma or any other respiratory disorder? *
    
8.
Do you have pain in your teeth 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 frequent popping, clicking or grating noises? *
         
12.
Do you have discomfort or pain when you open or close your mouth? *
         
13.
Do you have pain or ringing in your ears? *