Self-Assesment Tests

Name *

First Name

Last Name

Do you SNORE loudly? *

Yes

No

Do you feel TIRED, fatigued or sleepy during 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

BMI more than 35 *

Yes

No

AGE over 50 years old *

Yes

No

NECK circumference > 40cm *

Yes

No

GENDER: Male *

Yes

No

Name *

First Name

Last Name