Initial Participant Form and Snore Survey
 

Medical Professional Name:

 
 

Participant's Initials: 

    
 

Participant's Age: 

    
 

Patient has Diabetes: 

 Yes  No  
1. Who in household snores? (check all that apply)
Medical Professional
Diabetes Patient
Partner 		   
     
2. Who will be using SnoreQuell? (check all that apply)
Medical Professional
Diabetes Patient
Partner 		   
     
3. On average how many times does your snoring wake you up each night?
None or Does not apply
1-2
3-4
4 or more		    
     
4. On average how many times does your partner’s snoring awake you each night?
None or Does not apply
1-2
3-4
4 or more