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Unanswered Questions will be Highlighted in Red.

1. How frequently do you experience or have you been told about snoring loud enough to disturb the sleep of others?

Never Rarely (less than once a week) Occasionally (1 – 3 times a week) Frequently (More than 3 times a week)

2. How often have you been told that you have "pauses" in breathing or stop breathing during sleep?

Never Rarely (less than once a week) Occasionally (1 – 3 times a week) Frequently (More than 3 times a week)

3. How much are you overweight?

Not at all Slightly (10 – 20 pounds) Moderately (20 – 40 pounds) Severely (More than 40 pounds)

4. What is your Epworth Sleepiness Score?

Less than 8 9 – 13 14 – 18 19 or greater

5. Does your medical history include:

High blood pressure Stroke Heart disease More than 3 awakenings per night (on the average) Excessive fatigue Difficulty concentrating or staying awake during the day