Do you occasionally snore? *

No

Yes

Would your bed partner consider your snoring to be louder than a person talking? *

No

Yes

Does your snoring occur almost every night? *

No

Yes

Is your snoring bothersome to your bed partner?

No

Yes

Do you feel that in some way your sleep is not refreshing or restful? *

No

Yes

Do you wake up at night or in the mornings with headaches? *

No

Yes

Do you experience fatigue during the day and have difficulty staying awake? *

No

Yes

Do you have trouble remembering things or paying attention during the day? *

No

Yes

Do you have high blood pressure? *

No

Yes

I don't know

Have you been previously diagnosed with sleep apnea? *

No

Yes

Were you put on CPAP therapy for treatment?

Skip if you have never been diagnosed with sleep apnea

No

Yes

If yes, are you still using your CPAP?

No, I never used my CPAP

A few nights a month

A few nights a week

Most nights

Every night

Name *

First Name

Last Name