| Dear Patient, | |||
| The following questions may help us to decide whether you may have disordered breathing during sleep related to muscle weakness. Please circle the most appropriate answer to each question. | |||
| Thank you for your cooperation. | |||
| Do you feel breathless, if | |||
| you lie down? (e.g. on your bed) | Yes (2) | Sometimes (1) | No (0) |
| you bend forward? (e.g. to tie your shoelaces) | Yes (2) | Sometimes (1) | No (0) |
| you swim in water or lay in a bath? | Yes (2) | Sometimes (1) | No (0) |
| Have you changed your position when in bed? | Yes (2) | No (0) | |
| Have you noticed a change in your sleep (waking more, getting up, poor quality sleep)? | Yes (2) | No (0) | |
Numbers in parentheses represent scores.