Assessment of sleepiness and a person’s risk for obstructive sleep apnea.  
1.      Do you snore? 
Yes ______
No _______
Don’t know   _______

2.      If you snore –your snoring is:
Slightly louder than breathing _______
As loud as talking _______
Louder than talking ________
Very loud. Can be heard in adjacent rooms _______

3.      How often do you snore?
Nearly every day ______
3-4 times a week _______
1-2 times a week _______
1-2 times a month _______
never or nearly never   ________

4.      Has your snoring ever bothered other people?
Yes ______
No _______

5.      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 ________

6.      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 ________

7.      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 _______

8.      Have you ever nodded off or fallen asleep while driving a vehicle?
Yes _______
No _______

If yes, how often does it occur?
Nearly every day _________ 
3-4 times a week _________
1-2 times a week __________
1-2 times a month _________
nearly or nearly never ________

9.      Do you have high blood pressure?
Yes _______
No ________

10.    Has your weight changed?
Increase _______
Decrease _______
No change ________

Delray Medical Center Sleep Laboratory provided this test.  If you have any questions, please call us at (561) 495-3171.