1. Complete the following:

2. Do you snore?

Yes  
No  
Don't know

If you snore:

3. Your snoring is?

Slightly louder than breathing
As loud as talking
Louder than talking
Very Loud. Can be heard in adjacent rooms.

4. How often do you snore?

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

5. Does your snoring bother other people?

Yes
No

6. 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 week
Never or nearly never

7. How often do you feel tired or fatigued after waking from your sleep?

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

8. During your waketime, do you feel tired, fatigued or not up to par?

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

9. Have you ever nodded off or fallen asleep while driving a vehicle?

Yes
No

10. Do you have high blood pressure?

Yes
No
Not Sure

Results:

Interpreting Final Results:

Two or more positive categories indicates high likelihood of sleep apnea. Please inform your physician or call Midwest sleep institute for consultation at 847-855-9700