Do you snore?

Yes

No

Don’t know

How loud is your snoring?

Breathing

Talking

Louder than talking

Very loud – can be heard in adjacent room

How often do you snore?

Nearly every day

3 to 4 times a week

1 to 2 times a week

1 to 2 times a month

Almost never

Has your snoring ever bothered others?

Yes

No

Don't Know

Have you been told you stop breathing during sleep?

Yes

No

How often do you feel tired after sleep?

Nearly every day

3 to 4 times a week

1 to 2 times a week

1 to 2 times a month

Almost never

While awake, do you feel tired?

Nearly every day

3 to 4 times a week

1 to 2 times a week

1 to 2 times a month

Almost never

Have you ever fallen asleep while driving?

Yes

No

If yes, how often does this occur?

Nearly every day

3 to 4 times a week

1 to 2 times a week

1 to 2 times a month

Almost never

Do you have high blood pressure?

Yes

No

Don't Know

Online Sleep Evaluation