Gender *

Male

Female

Other

1. Do you snore?

Yes

No

Don't know

2. Your snoring is:

slightly louder than breathing

As loud as talking

Louder than talking

3. How often do you snore?

Almost every day

3-4 times per week

1-2 times per week

1-2 times per month

Rarely or never

4. Has your snoring ever bothered other people?

Yes

No

Don't know

5. Has anyone noticed that you stop breathing during your sleep?

Almost every day

3-4 times per week

1-2 times per week

1-2 times per month

Rarely or never

6. How often do you feel tired or fatigued after you sleep?

Almost every day

3-4 times per week

1-2 times per week

1-2 times per month

Rarely or never

7. During your waking time, do you feel tired, fatigued or not up to par?

Almost every day

3-4 times per week

1-2 times per week

1-2 times per month

Rarely or never

8. Have you ever nodded off or fallen asleep while driving a vehicle?

Yes

No

9. How often does this occur?

Almost every day

3-4 times per week

1-2 times per week

1-2 times per month

Rarely or never

10. Do you have high blood pressure?

Yes

No

Don't know