First Name
Name
Tel
Email
 
Weight
Size
Sex
Male Female
Age
Sleeping position
Smoking
Yes No
Allergies
Yes No
Use of tranquilizers
Yes No
Alcohol intake
Yes No
Tired in the morning
Yes No
High blood pressure
Yes No
Falling asleep during the day
Yes No
Sleepiness in your job or when driving
Yes No
Snoring heavily
Yes No

Your message:

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