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

1. Struggling to stay awake during the day Not at all Just a Little Pretty Much Very Much

2. Difficulty staying awake while driving Not at all Just a Little Pretty Much Very Much

3. Difficulty staying awake stopped at a traffic signal Not at all Just a Little Pretty Much Very Much

4. Difficulty staying awake at work or while doing tasks Not at all Just a Little Pretty Much Very Much

5. Difficulty staying awake while reading or studying Not at all Just a Little Pretty Much Very Much

6. Difficulty staying awake in social situations Not at all Just a Little Pretty Much Very Much

1. Feeling tired when at work or while doing tasks Not at all Just a Little Pretty Much Very Much

2. Lack of energy during social situations Not at all Just a Little Pretty Much Very Much

3. Struggling with fatigue during the day Not at all Just a Little Pretty Much Very Much

4. Feeling tired while reading or studying Not at all Just a Little Pretty Much Very Much

5. No energy to do tasks that do not absolutely have to be done Not at all Just a Little Pretty Much Very Much

6. Difficulty driving because of fatigue Not at all Just a Little Pretty Much Very Much

1. Sitting and reading Never Slight Moderate High

2. Watching TV Never Slight Moderate High

3. Sitting, inactive in a public place (e.g. a theater or a meeting) Never Slight Moderate High

4. As a passenger in a car for an hour without a break Never Slight Moderate High

5. Lying down to rest in the afternoon Never Slight Moderate High

6. Sitting and talking to someone Never Slight Moderate High

7. Sitting quietly after a lunch without alcohol Never Slight Moderate High

8. In a car, while stopped for a few minutes in traffic Never Slight Moderate High