| Name: | |
| E-mail: | |
| Phone Number: | |
| 1. Do you regularly feel un-refreshed, even after waking from a full night's sleep? | |
| 2. Do you fall asleep easily during your waking hours, while at home or at work? | |
3. Are you a loud, habitual snorer?
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4. Has your bed partner witnessed you choking, gasping, or holding your breath during sleep?
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| 5. Do you often suffer from poor concentration or judgment, memory loss, irritability and/or depression? | |
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