Date of birth

Gender Male Female

Ethnicity White African American Hispanic Asian or Pacific Islander American Indian/Alaskan Native Other

Comorbidity (check all that apply) Sleep apnea Diabetes (type 2) GERD Obesity-hypoventilation syndrome High cholesterol Cardiovascular disease

Are you of Asian descent? Yes No

Weight in pounds

First name

Last name

Phone number

E-mail address

Street address

City