1. Do you smoke?
Yes
Sometimes
No

3. Have you been told you snore?
Yes
Sometimes
No

5. Do you have morning headaches?
Yes
Sometimes
No

7. Do you have difficulty losing weight?
Yes
Sometimes
No

9. Do you have acid reflux?
Yes
Sometimes
No

11. Do you take any antidepressants or sleep aids?
Yes
Sometimes
No

13. Do you take medications for impotence?
Yes
Sometimes
No

2. Do you drink alcohol close to bedtime?
Yes
Sometimes
No

4. When you get 7 to 8 hours of sleep, are you still fatigued or sleepy during the day?
Yes
Sometimes
No

6. Are you more than 10% above ideal body weight?
Yes
Sometimes
No

8. Do you have hypertension?
Yes
Sometimes
No

10. Do you have insomnia?
Yes
Sometimes
No

12. Do you have difficulty remembering names?
Yes
Sometimes
No