Age (years) 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9  

Gender 0 = Female 1 = Male  

Height (inches)) ? 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9  

Weight (pounds)? 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9  

Do you snore ?   0 = never 1 = less than once per week 2 = 1 to 2 times per week 3 = 3 to 4 times per week 4 = 5 to 7 times per week

Do you snort or choke while you are asleep?   0 = never 1 = less than once per week 2 = 1 to 2 times per week 3 = 3 to 4 times per week 4 = 5 to 7 times per week

Do you stop breathing or struggle for breath while you are sleeping? 0 = never 1 = less than once per week 2 = 1 to 2 times per week 3 = 3 to 4 times per week 4 = 5 to 7 times per week