Check 'Yes' or 'No' to the questions below, then click 'Submit.
(Ask your partner, housemate, etc. to help you answer the first 2 questions.)

1) Do you snore most nights? yes no

2) Is your snoring interrupted by silence followed by a gasp or snort? yes no

3) Do you ever fall asleep -- or almost fall asleep -- while driving, at work or during other waking hours? yes no

4) Do you regularly have trouble concentrating or remembering? yes no

5) Do you have high blood pressure? yes no

6) Do you often wake up with a headache? yes no

7) Do you drink more than 2 caffeine containing beverages a day? yes no

*If you answered yes to any questions, your symptom(s) may be from sleep apnea or some other sleep related problem. Either way, medical attention is important! Please provide your contact information so that we can send you information on how the Scottsdale Sleep Center can help you.

Name	e-mail address
Address	City	Zip

*The Scottsdale Sleep Center will not sell your information or provide it to third party organizations. We respect your privacy and will keep your personal information confidential. Your contact information will soley be used to send you information regarding your sleep quiz.