I am answering for:

Myself

Spouse/Partner

Other

I snore:

Yes

No

I am tired, fatigued or sleepy during the day:

Yes

No

I have used a CPAP (Continuous Positive Airway Pressure):

Yes

No

My snoring is loud:

Never(0)

Infrequently (1)

Frequently (2)

Most of the time (3)

Snoring affects my relationship:

Never (0)

Infrequently (1)

Frequently (2)

Most of the time (3)

My snoring causes me or my partner to be irritated/sleepy during the day:

Never (0)

Infrequently (1)

Frequently (2)

Most of the time (3)

My snoring requires me to sleep in a separate room:

Never (0)

Infrequently (1)

Frequently (2)

Most of the time (3)

My snoring affects other people when sleeping away from home (hotel, camping, etc.): 

Never (0)

Infrequently (1)

Frequently (2)

Most of the time (3)

Total Score:

0 .. 1:    You are not currently experiencing symptoms for Obstructive Sleep Apnea
2 .. 3:    You have non-threatening symptoms at this time but should see your dentist if symptoms increase
4 .. 5:    Your health is at immediate risk, talk to your dentist about taking precautions
6+ .. :    You are at immediate and serious risk for Obstructive Sleep Apnea (OSA) - see your dentist today!    

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