do or do not , there is no try check that box Full Name Email Phone number Do you snore while you sleep? Yes No I don't know If you snore, how severe is your snoring? Not loud About as loud as talking Louder than talking Considerably loud How frequently do you snore? Almost never Only once or twice a month Only once or twice a week 3 to 4 times each week Almost every day Has the level of your snoring bothered others? Yes No I don't know Have you ever been told that you stop breathing while you sleep? Yes No How frequently do you feel tired or fatigued following sleep? Almost never Only once or twice a month Only once or twice a week 3 to 4 times each week Almost every day Do you ever abruptly awaken with a gasping or choking sensation? Yes No I don't know Have you ever nodded off while driving? Yes No If you have ever fallen asleep while driving, how often has it occurred? Almost never Only once or twice a month Only once or twice a week 3 to 4 times each week Almost every day Do you have hypertension (high blood pressure)? Yes No I don't know
