1. Do you ever wake yourself up by snoring?
YesNo

2. Does your partner ever wake you and tell you to turn over?
YesNo

3. Do family members comment on how loud you snore?
YesNo

4. Is your energy level down and you feel you need more sleep?
YesNo

5. Do you fall asleep while watching television or reading?
YesNo

6. Have you fallen asleep during the day?
YesNo

7. Do you ever feel like you have brain fog?
YesNo

8. Have you had memory problems?
YesNo

Would you like our offices to contact you to set an appointment with Dr. Shuaib?
YesNo