Is VitalSleep Right for You?


VitalSleep® is a Class II medical device that has been cleared by the FDA. 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.

Note: The Snore Reliever Company is not liable for any damages or injuries resulting from false or erroneous information provided by you.
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, wear braces or have a new dental implant within the past year. *
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 chronic emphysema, asthma or any other respiratory disorder? *
No
Yes
8.
Do you have pain or difficulty with in your teeth or with chewing/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 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.
Do you agree to the Terms and Conditions? Terms & Conditions *
Yes
No



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