Yes No
❍ ❍ Do you SNORE Loudly? (Loud enough to be heard with a door closed)
❍ ❍ Do you often feel TIRED, fatigued, or Sleepy during the day?
❍ ❍ Has anyone OBSERVED you stop breathing (gasping/choking) during your sleep?
❍ ❍ Do you have or are you being treated for high blood PRESSURE?
❍ ❍ BMI Greater than 35? *See link below.
❍ ❍ Are you older than 50 years of AGE?
❍ ❍ NECK circumference greater than 40 cm? (size 17 collar)
❍ ❍ GENDER are you a Male?