Answer each question as accurately as you can. At the end of the questionnaire, fill in your name, email address, phone and other requested data (all optional). This information is only used to communicate results back to you. All names, phone numbers, etc. are purged after their intended use and are not made available to any other organization, commercial entity or individual.
How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? This refers to your usual way of life in recent times. Even if you have not done some of these things recently try to work out how they would have affected you. Use the following scale to choose the most appropriate number for each situation.
0= Would never doze 1 = Slight chance of dozing 2 = Moderate chance of dozing 3 = High chance of dozing
Sitting and reading 0 1 2 3
Watching TV 0 1 2 3
Sitting inactive in a public place (e.g. a theater or a meeting) 0 1 2 3
As a passenger in a car for an hour without a break 0 1 2 3
Lying down to rest in the afternoon when circumstances permit 0 1 2 3
Sitting and talking to someone 0 1 2 3
Sitting quietly after a lunch without alcohol 0 1 2 3
In a car, while stopped for a few minutes in the traffic 0 1 2 3
1) Do you sometimes experience a creeping feeling in your legs? Yes No
2) Do you or have you ever been told that you kick your legs at night? Yes No
3) Do you snore? Yes No I don't know
If "yes" please continue with #4
If "no" or "I donít know" please continue with #8
4) Your snoring is... softer than talking as loud as talking louder than talking
5) Your snoring occurs... every/almost every night a few times each week once a week or less
6) Your snoring is also... frequently interrupted by pauses/choking occasionally interrupted by pauses/choking not interrupted as far as you know
7) Do you snore in every body position? Yes No I don't know
8) Do you have, or ever had a bed partner? Yes No
If "yes" please continue with #9
If "no" please continue with #12
9) Has your bed partner ever said that you have pauses in your breathing or periods of stopped breathing during your sleep? Yes No
10) Has your bed partner ever commented that you snore? Yes, loud snoring Yes, soft snoring No
11) If you snore, is it loud enough to bother her/him? Yes No
12) Has anyone besides a bed partner ever commented on your snoring (roommate, neighbor, family, etc.)? Yes, loud snoring Yes, soft snoring No
13) Do you feel fatigued or exhausted or tired or not up to par? nearly every day 3 to 4 times a week once or twice a week once or twice a month never or hardly ever
14) Do you feel that in some way your sleep is not refreshing or restful? nearly every day 3 to 4 times a week once or twice a week once or twice a month never or hardly ever
15) Do you have periods of the day when you have trouble paying attention, remembering things or staying awake? nearly every day 3 to 4 times a week once or twice a week once or twice a month never or hardly ever
16) Do you have high blood pressure? Yes No
If "yes" are you being treated for high blood pressure? Yes No
17) Do you wake up during the night or in the morning with headaches? Yes No
18) Are you a shift worker? Yes No
19) Do you have trouble initiating and/or maintaining sleep? nearly every day 3 to 4 times a week once or twice a week once or twice a month never or hardly ever
20) What do you feel is your ideal amount of sleep per day? 2-4 5 6 7 8 9 10
21) Estimate the average number of hours of sleep you had per day during the last week. 2-4 5 6 7 8 9 10