The Put an End to Snoring Questionnaire
First, some questions about your health....
1. At what age did snoring become a problem for you? Under 25 25-35 36-45 Over 46
2. Has your snoring worsened in the last year or two? Yes No
3. Have you put on more than 10 lbs in the last year or so? Yes No
4. Is your shirt collar size greater than 17 (man) or 16 (woman) Yes No
5. Do you smoke? Yes No
6. Do you usually have an alcoholic drink within a few hours of going to bed? Yes No
7. Does your doctor say that you have high blood pressure? Yes No
8. Do you often wake up with a morning headache? Yes No
9. Do you often have a stuffy nose at night, perhaps from allergies or other nasal conditions? Yes No
10. Have you had your tonsils removed? Yes No
Now, your behavior while you sleep....
11. Have you been told you snore loudly? Yes No
12. Do you snore almost every night? Yes No
13. Do you usually breathe through your nose or through your mouth at night? Nose Mouth
14. Have you been told that you appear to stop breathing when you sleep then suddenly start breathing again with a snort or gasp? Yes No
15. Have you ever awakened with a gasping or choking sensation? Yes No
16. Do you toss and turn frequently in the night? Yes No
17. If you did not have a bed partner or roommate, would you be unaware that you snore? Yes No
18. Do you snore less while sleeping on your side? Yes No
This section concerns your sleepiness. For each of the following situations, how likely you are to doze off?
19. Sitting and reading Never Slight chance Moderate chance High chance
20. Watching TV Never Slight chance Moderate chance High chance
21. Sitting in a public place (such as a meeting) Never Slight chance Moderate chance High chance
22. As a passenger in a car Never Slight chance Moderate chance High chance
23. Lying down for a nap Never Slight chance Moderate chance High chance
24. Sitting and talking to someone Never Slight chance Moderate chance High chance
25. Sitting quietly after lunch Never Slight chance Moderate chance High chance
26. Driving a car, stopped in traffic for a few minutes Never Slight chance Moderate chance High chance
This page based on Epworth Sleepiness Scale.
Questionnaire and analysis methodology copyright � 2001-5 Deo Gloria, LLC.
