1. Has anyone ever told you that you snore?

If yes, how loud? 1 2 3 4 5 6 7 8 9 10

2. Does your snoring ever bother anyone?

3. Have you ever been told that you stop breathing while you sleep?

4. Do you awaken gasping, choking, or have shortness of breath?

5. Do you have trouble staying asleep once you fall asleep?

6. Do you have morning or daytime headaches?

7. Do you feel tired or fatigued throughout the day?

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

9. Do you have high blood pressure?

10. Do you have indigestion?

11. Have you had memory loss?

12. Do you ever awaken with intense anxiety?

13. Do you ever experience depressed feelings?

14. Do you notice a decreased ability to think effectively?

15. Do you ever take naps?

If yes, how ofter per week? 1 2 3 4 5 6 7

16. Do you notice a decreased sexual interest?

17. Do you smoke?

18. Are you overweight?