Are you at risk of Sleep Apnea?

Please completed the questions below and find out.

1. Do you snore?

Yes No Dont' know

If you snore:
2. Your snoring is?

Slightly louder than breathing As loud as talking Louder than talking Very loud - can be heard in adjacent rooms

3. How often you snore?

Nearly every day 3-4 times a week 1-2 times a week 1-2 times a month Never or nearly never

4. Has your snoring ever bothered other people?

Yes No Dont' know

5. Has anyone noticed that you quit breathing during your sleep?

Nearly every day 3-4 times a week 1-2 times a week 1-2 times a month Never or nearly never

6. How often do you feel tired or fatigued after your sleep?

Nearly every day 3-4 times a week 1-2 times a week 1-2 times a month Never or nearly never

7. During your waking time, do you feel tired, fatigued or not up to par?

Nearly every day 3-4 times a week 1-2 times a week 1-2 times a month Never or nearly never

8. Have you ever nodded off or fall asleep while driving a vehicle?

Yes No If yes, how often does this occur?
Nearly every day 3-4 times a week 1-2 times a week 1-2 times a month Never or nearly never

9. Do you have high blood pressure?

Yes No Dont' know

10. BMI > 30

Yes No

You have a high likelihood of sleep apnea.

You have a low likelihood of sleep apnea.

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