| Height (m) __________ Weight (kg) __________ Age __________ Male/Female Please choose the correct response to each question. | |
| Category 1 | 1. Do you snore? _ a. Yes _ b. No _ c. Don't know If you snore: 2. Your snoring is: _ a. Slightly louder than breathing _ b. As loud as talking _ c. Louder than talking _ d. Very loud – can be heard in adjacent rooms 3. How often do you snore _ a. Nearly every day _ b. Three to four times a week _ c. One to two times a week _ d. One to two times a month _ e. Never or nearly never 4. Has your snoring ever bothered other people? _ a. Yes _ b. No _ c. Don't know 5. Has anyone noticed that you quit breathing during your sleep? _ a. Nearly every day _ b. Three to four times a week _ c. One to two times a week _ d. One to two times a month _ e. Never or nearly never |
| Category 2 | 6. How often do you feel tired or fatigued after your sleep? _ a. Nearly every day _ b. Three to four times a week _ c. One to two times a week _ d. One to two times a month _ e. Never or nearly never 7. During your waking time, do you feel tired, fatigued or not up to par? _ a. Nearly every day _ b. Three to four times a week _ c. One to two times a week _ d. One to two times a month _ e. Never or nearly never 8. Have you ever nodded off or fallen asleep while driving a vehicle? _ a. Yes _ b. No If yes: 9. How often does this occur? _ a. Nearly every day _ b. Three to four times a week _ c. One to two times a week _ d. One to two times a month _ e. Never or nearly never |
| Category 3 | 10. Do you have high blood pressure? _ Yes _ No _ Don't know |
