Enter the corresponding answer (number) to each question in
the right column under Score.  When you have completed
the Screening Tool, click the submit button at the bottom.
									Score
1. Do you snore on most nights (>3 nights per week)?
	Yes	2		No	0
2. Is your snoring loud? Can it be heard through a door or wall?
	Yes	2		No	0
3. Have you ever been told that you stop breathing or gasp during sleep?
	Never	0	Occasionally		3	Frequently		5
4. What is your collar size?
	Male	Less than 17"		0	More than 17"		5
	Female	Less than 16"		0	More than 16"		5
5. Do you occasionally fall asleep during the day when:
	a) You are busy or active?
	Yes	2		No	0
	b) You are driving or stopped at a light?
	Yes	2		No	0
6. Have you had or are you being treated for High Blood Pressure?
	Yes	1		No	0
							Total
If you would like us to contact you regarding your sleep screening results,
enter your name and phone number or e-mail address below.
Name:				Phone:
E-mail: