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Name Date / /
DD MM YY
You may be asked to complete this questionnaire each time you visit RANA, as we would like to objectively understand
to what extent your sleep apnea and/or snoring is having an impact on your daily activities, emotions, social
interactions, and about symptoms that may have resulted. Measuring that prior to starting any treatment, and then
again at various stages after starting treatment, is very important. Please insert the best (Response #) that
reflects your response to each Situation described.
SITUATIONS # RESPONSE #
1. Sitting and reading No chance of dozing 0
Slight chance of dozing 1
2. Watching television
Moderate chance of dozing 2
3. Sitting inactive in a public place (e.g. a theatre or meeting)
High chance of dozing 3
4. As a passenger in a car for an hour without a break
SC 5.00pre