Category 1
Do you snore?
___ Yes
___ No
___ Don’t Know
Your snoring is?
___ Slightly louder than breathing
___ As loud as breathing
___ Louder than talking
___ Can be heard in adjacent room
Describe the snoring frequency
___ Nearly every day
___ 3-4 times a week
___ 1-2 times a week
___1-2 times a month
___ Never or nearly ever
Has your snoring ever bothered other people?
___ Yes
___ No
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
Category 2
How often do you feel tired or fatigued after you sleep?
___ Nearly every day
___ 3-4 times a week
___ 1-2 times a week
___ 1-2 times a month
___ Never or nearly never
During your wake 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
Have you ever nodded off or fallen 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
Category 3
Do you have high blood pressure?
___ Yes
___ No
BMI= mass (kg) / (height (M))2 = mass (lbs) / (height (inches))2 x 703 =_______________
Category 1 positive (>2) ______
Category 2 positive (>2) ______
Category 3 positive (1 or BMI > 30) ______
HIGH RISK if there are 2 or more Categories where the score is positive
LOW RISK if there are one or no Categories where the score is positive