1. Do you wake up in the morning feeling unrefreshed or tired? *

Yes

No

2. Have you ever been told you snore? *

Yes

No

3. Do you struggle, gasp, or stop breathing at night? *

Yes

No

4. Do you ever get morning headaches? *

Yes

No

5. Do you have a hard time staying awake during the day? *

Yes

No

6. Have you ever fallen asleep while driving a car? *

Yes

No

7. Do you have trouble staying asleep? *

Yes

No

8. Do you have a hard time remembering things or focusing on tasks? *

Yes

No

9. Do you have high blood pressure? *

Yes

No

Name *

First Name

Last Name

Phone *

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