Do you have difficulty concentrating during the day?
1. Never
2. Rarely
3. Sometimes
4. Often
5. Very Often
How often do you wake up with morning headaches?
1. Never
2. Rarely
3. Sometimes
4. Often
5. Very Often
How often do you awaken with a dry mouth in the morning?
1. Never
2. Rarely
3. Sometimes
4. Often
5. Very Often
How often do you engage in loud snoring?
1. Never
2. Rarely
3. Sometimes
4. Often
5. Very Often
How often do you awake gasping for breath during sleep?
1. Never
2. Rarely
3. Sometimes
4. Often
5. Very Often
How often do you experience daytime sleepiness?
1. Never
2. Rarely
3. Sometimes
4. Often
5. Very Often
Describe your body weight.
1. Under weight
2. Good
3. Slightly Over Weight
4. Lower Over Weight
5. Very Over Weight
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Last Name
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