1. Snoring: Do you snore loudly (loud enough to be heard through chosed doors)? Yes No

2. Tired: Do you often feel tired, fatigued, or sleepy during daytime? Yes No

3. Observed: Has anyone observed you stop breathing during your sleep? Yes No

4. Blood Pressure: Do you have or are you being treated for high blood pressure? Yes No

5. BMI What is your height in inches: What is your weight in lbs:

6. Age: Are you over 50 years old? Yes No

7. Neck circumference: Is your neck size larger than 16"? Yes No

8. Gender: Are you a male? Yes No