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If you have a problem snoring or suspect you may be suffering from sleep apnea, take a moment to complete the following questionaire.

How likely are you to doze off or fall asleep during the following situations in contrast to feeling just tired? This refers to your usual way of life in recent times. Even if you have not done some of these things recently, try to work out how they would have affected you.

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.
1. Sitting and reading.
2. Watching TV.
3. Sitting inactive in a public place. (e.g. theater or meeting)
4. As a passenger in a car for an hour without a break.
5. Lying down to rest in the afternoon when circumstances permit.
6.  Sitting and talking to someone.
7.  Sitting quietly after lunch without alcohol.
8.  In a car while stopped for a few minutes in traffic.
Total Score

Behavior During Sleep
Use the following scale to choose the most appropriate number for each situation.

0= Never during a usual night.
1= Less than once per week.
2= Once to about half the nights per week.
3= Half the nights to almost always.
4= Every night.
?= Don't know; haven't been told.
1. Snore loudly.
2. Stop breathing.
3. Choke, struggle for breath.
4. Toss and turn frequently.
5. Wake up with a headache.
6. Usual amount of hours you sleep each night.
7. Number of times you rise to use the restroom.
Total Score
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