Phone
(02) 9232 3337
Fax
(02) 9232 7295
CML Building, 14 Martin Place, Level 12,
Suite 1203, Sydney 2000 Australia
Snoring Quick Self Assessment
Yes
No
(please tick)
1. Do you snore loudly?
2. Do you snore every night?
3. Have you or your partner moved to
another bedroom?
4. Do you choke or gasp during sleep?
5. Have you woken short of breath during
the night?
6. Have you been told you hold your breath
during sleep?
7. Are you restless during sleep?
8. Do you have toilet visits during the night?
9. Do you suffer heartburn (indigestion) at
night?
10. Do you suffer morning headaches?
11. Are you irritable on waking in the morning?
12. Do you suffer excessive daytime sleepiness?
13. Have you dozed off while driving?
14. Do you fall asleep at meetings, reading or
watching TV?
15. Are you drowsy in the afternoon?
16. Are you tired upon waking? (lethargic, no
energy)
17. Reduced sexual activity?
18. Do you suffer from High Blood Pressure?
Your Details
1st Name
(required)
Surname
Daytime Phone number
(required)
Mobile
Email
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