FORM.

NO:

RESEARCH QUESTIONNAIRE
Hello! Thank you for taking the time to participate in this research study on obstructive sleep apnea.
Please be assured that all information you provide will be kept strictly confidential and used for
research purposes only.

AGE: GENDER: OCCUPATION:

RESIDENCE:

1. Complete the following: 7. How often do you feel tired or fatigued after your
sleep?
Height: Weight: Nearly every day
3-4 times a week
2. Do you snore? 1-2 times a week
Yes 1-2 times a month
No never or nearly never
Don't know
8. During your wake time, do you feel tired,
If you snore: fatigued, or not up to par?
Nearly every day
3. Your snoring is… 3-4 times a week
Slightly louder than breathing 1-2 times a week
As loud as talking 1-2 times a month
Louder than talking never or nearly never
Very loud, can be heard in adjacent rooms
9. Have you ever nodded off or fallen asleep while
4. How often do you snore? driving a vehicle?
Nearly every day Yes
3-4 times a week No
1-2 times a week If yes, how often does it occur?
1-2 times a month Nearly every day.
never or nearly never 3-4 times a week
1-2 times a week
5. Has your snoring ever bothered other people? 1-2 times a month
Yes never or nearly never
No
10. Do you have high blood pressure?
6. Has anyone noticed that you quit breathing Yes
during your sleep? No
Nearly every day. Don't know
3-4 times a week
1-2 times a week BMI (Body mass index) =
1-2 times a month
never or nearly never
 Next, I am going to ask you about the time you spend doing different types of physical activity in a
typical week. Please answer these questions even if you do not consider yourself to be a physically
active person.
Rarely or none Some or a Occasionally
of the time little of the or a moderate Most or all of the
PHYSICAL ACTIVITY (less than 1 time (1-2 amount of the time (5-7 days)
day) days) time (3-4
days)
ACTIVITY AT WORK
1- Does your work involve vigorous-intensity
activity (like digging, Carrying, loading or
stacking heavy loads such as rocks or wood,
Chopping wood or rocks with axe, Masonry,
concrete and shoveling, Selling
vegetables/fruits/milk/fish in bicycles, Drawing
water from well , Servant maid , Manual grinding
etc. ) that causes large increases in
breathing or heart rate for at least 10
minutes continuously?
2- Does your work involve moderate-intensity
activity (like Carrying, loading or stacking moderate loads
such as bricks or stones , Child care: dressing, bathing,
grooming, feeding and occasional lifting of the child, Patient
care and elderly care , Mopping floor with hands , Gardening:
watering plants, pruning, sowing seeds, cleaning, etc ) that
causes small increases in breathing or heart rate for
at least 10 minutes continuously?
TRAVEL TO AND FROM PLACES
3-Do you walk or use a bicycle (pedal cycle) for at
least 10 minutes continuously to get to and from
places (like to work, To market, to bring children from school,
To see friends, relatives or others, to shops, To temple, church
or mosque or religious places etc) ?
RECREATIONAL ACTIVITIES
4- Do you do any vigorous-intensity sports, fitness
or recreational (leisure) activities
( Like jogging ,running, football , kaleri,swimming, skipping
etc.) that cause large increases in breathing or heart
rate for at least 10 minutes continuously?
5- Do you do any moderate-intensity sports, fitness
or recreational (leisure) activities
(like brisk walking, Animal care: feeding, bathing, cleaning
animal house, Gardening: watering plants, pruning, sowing
seeds, cleaning ,exercise, volleyball, dancing etc) that causes
a small increase in breathing or heart rate such as
brisk walking for at least 10 minutes continuously?
SEDENTARY BEHAVIOUR
6- How much time do you usually spend sitting or
reclining on a typical day?

SMOKING HABIT
7-Which of the following best describes your
smoking status?
Never Smoked
Former Smoker (quit >1year ago)
Current Smoker (<1 pack/day)
Current Smoker (1-2 packs/day)
Current Smoker (>2 packs/day)
THIS IS Center for Epidemiologic Studies Depression Scale (CES-D Scale)

Instructions: Please read each question carefully, then circle one of the numbers to the right
to indicate how you felt or behaved during the past week, including today.

Rarely or none Some or a Occasionally or a Most or all of

of the time little of the moderate amount the time (5-7
(less than 1 time (1-2 of the time (3-4 days)
day) days) days)
During the past week: 0 1 2 3
1) I was bothered by things that 0 1 2 3
usually don’t bother me
2) I did not feel like eating; my 0 1 2 3
appetite was poor
3) I felt that I could not shake off 0 1 2 3
the blues even with help from my
family and friends
4) I felt that I was just as good as 0 1 2 3
other people
5) I had trouble keeping my mind on 0 1 2 3
what I was doing
6) I felt depressed 0 1 2 3
7) I felt that everything I did was an 0 1 2 3
effort
8) I felt hopeful about the future 0 1 2 3
9) I thought my life had been a 0 1 2 3
failure
10) I felt fearful 0 1 2 3
11) My sleep was restless 0 1 2 3
12) I was happy 0 1 2 3
13) I talked less than usual 0 1 2 3
14) I felt lonely 0 1 2 3
15) People were unfriendly 0 1 2 3
16) I enjoyed life 0 1 2 3
17) I had crying spells 0 1 2 3
18) I felt sad 0 1 2 3
19) I felt that people disliked me 0 1 2 3
20) I could not get “going” 0 1 2 3