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 snore? Yes No I don't know
If "yes" please continue with #2
If "no" or "I donít know" please continue with #7
2) Your snoring is... softer than talking as loud as talking louder than talking
3) Your snoring occurs... every/almost every night a few times each week once a week or less
4) Do you snore in every body position? Yes No I don't know
5) Your snoring is ALSO... frequently interrupted by pauses/choking occasionally interrupted by pauses/choking not interrupted as far as you know
6) Is your snoring bothersome to others? Yes No
7) Has anyone ever said that you stop breathing or have pauses in your breathing during your sleep? Yes No
8) Do you wake up suddenly for no reason during the night? Yes No
9) Do you sometimes experience a tingling feeling in your legs or kick your legs at night? Yes No
10) Do you have trouble falling or staying asleep? nearly every day 3 to 4 times a week once or twice a week once or twice a month never or hardly ever
11) Do you take any medicine to help you sleep? Yes No Please name the medicine:
12) How many hours of sleep do you think you need per night? 2-4 5 6 7 8 9 10
13) How many hours of sleep do you usually get per night? 2-4 5 6 7 8 9 10
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 feel fatigued, exhausted or tired? 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 take naps? Nearly every day Whenever I can Never or hardly ever
17) 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
18) Do you have high blood pressure? Yes No i don't know
19) Do you have Diabetes? Yes No i don't know
20) Do you wake up during the night or in the morning with headaches? Yes No
21) Does a family member have a sleep disorder? Yes No Please name the type of disorder:
22) Are you a shift worker? Yes No
23) Do you drink alcohol? Yes No How many drinks do you have each week?
24) Do you drink caffeine (Coffee/Tea, Soda/ Energy Drinks)? Yes No How many drinks (8 oz.) do you have each day?
25) Do you experience pain or discomfort while sleeping? Yes No Please try to describe the sensation: