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Category 1.
points
1. Do you snore?
a. Yes
b. No
c. Don't
Know
If you snore
2. Your snoring is:
a. Slightly louder than breathing
b. As loud as talking
c. Louder than talking
d. Very loud -can be heard in adjacent rooms
3. How often do you snore?
a. Nearly every day
b. 3 to 4 times a week
c. 1 to 2 times a week
d. 1-2 times a month
e. Never or nearly never
4. Has your snoring ever bothered other
people?
a. Yes
b. No
c. Don't know
5 Has anyone noticed that you quit breathing during your sleep?
a. Nearly every day
b. 3 to 4 times a week
c. 1 to 2 times a week
d. 1 to 2 times a month
e. Never or nearly never
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Category 2
points
6. How often do you
fell tired or fatigued after your sleep?
a. Nearly every day
b. 3 to 4 times a week
c. 1 to 2 times a week
d. 1 to 2 times a
month1
e. Never or nearly never
7. During your waking time, do you feel tired, fatigued or not up to
par?
a. Nearly every day
b. 3 to 4 times a week
c. 1 to 2 times a week
d. 1 to 2 times a month\
e. Never or nearly never
8. Have you ever nodded off or fallen asleep while driving a vehicle?
a. Yes
b. No
If Yes :
9. How often does this occur?
a. Nearly every day
b. 3 to 4 times a week
c. 1 to 2 times a week
d. 1 to 2 times a month
e.
Never or nearly never.
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