1. Complete the following:
2. Do you snore? Yes No Don't Know
If your snore:
3. Your snoring is? slightly louder than breathing as loud as talking louder than talking very loud. Can be heard in adjacent room
4. How often do you snore? nearly every day 3-4 times a week 1-2 times a week 1-2 times a month never or nearly never
5. Has your snoring ever bothered other people? Yes No
6. Has anyone noticed that you quit breathing during your sleep? nearly every day 3-4 times a week 1-2 times a week 1-2 times a month never or nearly never
7. How often do you feel tired or fatigued after your sleep? nearly every day 3-4 times a week 1-2 times a week 1-2 times a month never or nearly never
8. During your waketime, do you feel tired, fatigued or not up to par? nearly every day 3-4 times a week 1-2 times a week 1-2 times a month never or nearly never
9. Have you ever nodded off or fallen asleep while driving a vehicle? Yes No
If yes, how often does it occur? nearly every day 3-4 times a week 1-2 times a week 1-2 times a month never or nearly never
10. Do you have high blood pressure? Yes No Don't Know
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Date: