Have you been told that you snore or know that you snore/make breathing noises while sleeping? *

Yes

No

Do you often feel tired, fatigued or sleepy during the day? *

Yes

No

Has anyone observed you stop breathing during sleep? *

Yes

No

Do you have or have you been treated for High Blood Pressure? *

Yes

No

Is your Body Mass Index (BMI) more than 35 lbs/in²? *

Yes

No

Is your Age more than 50 years old? *

Yes

No

Is your Neck circumference greater than 16 inches? *

Yes

No

Is your Gender male? *

Yes

No

Name *

First Name

Last Name