1. At what age did snoring become a problem for you? Under 25
25-35
36-45
Over 46
2. Has your snoring worsened in the last year or two? Yes No
3. Have you put on more than 10 lbs in the last year or so? Yes No
4. Is your shirt collar size greater than 17 (man) or 16 (woman) Yes No
5. Do you smoke? Yes No
6. Do you usually have an alcoholic drink within a few hours of going to bed? Yes No
7. Does your doctor say that you have high blood pressure? Yes No
8. Do you often wake up with a morning headache? Yes No
9. Do you often have a stuffy nose at night, perhaps from allergies or other nasal conditions? Yes No
10. Have you had your tonsils removed? Yes No

Now, your behavior while you sleep....
11. Have you been told you snore loudly? Yes No
12. Do you snore almost every night? Yes No
13. Do you usually breathe through your nose or through your mouth at night? Nose Mouth
14. Have you been told that you appear to stop breathing when you sleep then suddenly start breathing again with a snort or gasp? Yes No
15. Have you ever awakened with a gasping or choking sensation? Yes No
16. Do you toss and turn frequently in the night? Yes No
17. If you did not have a bed partner or roommate, would you be unaware that you snore? Yes No
18. Do you snore less while sleeping on your side? Yes No
19. Do you suffer from headaches, migraines or facial pain? Yes No
20. Do you suffer from sore neck, shoulder or back pain? Yes No

This section concerns your sleepiness. For each of the following situations, how likely you are to doze off?
21. Sitting and reading Never
Slight chance
Moderate
High chance
22. Watching TV Never
Slight chance
Moderate
High chance
23. Sitting in a public place (such as a meeting) Never
Slight chance
Moderate
High chance
24. As a passenger in a car Never
Slight chance
Moderate
High chance
25. Lying down for a nap Never
Slight chance
Moderate
High chance
26. Sitting and talking to someone Never
Slight chance
Moderate
High chance
27. Sitting quietly after lunch Never
Slight chance
Moderate
High chance
28. Driving a car, stopped in traffic for a few minutes Never
Slight chance
Moderate
High chance