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| Question |
Please check Yes or No for each question |
| Do you snore loudly (louder than talking or loud enough to be heard through closed doors)? |
🗆 Yes 🗆 No |
| Do you often feel tired, fatigued, or sleepy during the daytime? |
🗆 Yes 🗆 No |
| Has anyone observed you stop breathing during your sleep? |
🗆 Yes 🗆 No |
| Do you have or are you being treated for high blood pressure? |
🗆 Yes 🗆 No |
| Is your Body Mass Index (BMI) greater than 35 kg/m²? |
🗆 Yes 🗆 No |
| Are you 50 years or older? |
🗆 Yes 🗆 No |
| Is your neck circumference greater than 40 cm (16 inches)? |
🗆 Yes 🗆 No |
| Are you male? |
🗆 Yes 🗆 No |
Total Score: ______ / 8
Low Risk: 0–2 Intermediate Risk: 3–4 High Risk: 5–8
Must be signed by a physician or nurse practitioner.