People are often unaware of their snoring and it often helps to have a bed partner or housemate help with the questions below.

First Name *

Last Name *

Phone *

Email *

Your Age (Years) *

Your Sex *

Your Sex

Do you Snore? *

Yes

No

If so How Often? How loud? *

Are you aware or have you been told you stop breathing, gasp for air or choke while sleeping? *

Yes

No

Do you have morning headaches? *

Yes

No

Do you wake up frequently during the night? *

Yes

No

Do you easily nod off to sleep when reading or watching TV? *

Yes

No

Do you feel tired or fatigued? *

Yes

No

Do you have poor concentration? *

Yes

No

How likely are you to doze off or fall asleep in the following situations?

Use the following scale to choose the most appropriate number for each situation:

0 = Would never doze
1 = Slight chance of dozing
2 = moderate chance of dozing
3 = High chance of dozing

Sitting and Reading *

Sitting and Reading

Watching TV *

Watching TV

As a passenger in a car for an hour without a break *

As a passenger in a car ...

Sitting, inactive in a public space (e.g. a theatre or a meeting) *

Sitting, inactive in a public space ...

Sitting and talking to someone *

Sitting and talking to someone ...

Lying down to rest in the afternoon when circumstances permit *

Lying down to rest in the afternoon ...

In a car, while stopped for a few minutes in the traffic *

In a car, while stopped for a few minutes ...

Sitting quietly after a lunch without alcohol

Sitting quietly after a lunch ...