Feel free to print this and fill it out before coming in to our office. Might also be a good idea to give a copy to that spouse who snores!

Patient Name:                                                                     Date of Birth:                            


In contrast to just feeling tired, how likely are you to doze off or fall asleep in the following situations? 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 or each situation.

                                          0 = WOULD NEVER DOZE

                                          1 = SLIGHT CHANCE OF DOZING

                                          2 = MODERATE CHANCE OF DOZING

                                          3 = HIGH CHANCE OF DOZING


SITUATION                                                                   CHANCE OF DOZING

Sitting and Reading    &nbnbsp;                                                                                      

Watching TV                                                                                                      

Sitting inactive in a public place (i.e., in a theatre)                                        

As a car passenger for an hour without a break                                           

Lying down to rest in the afternoon                                                                

Sitting and talking to someone                                                                          

Sitting quietly after lunch (without alcohol)                                                   

In a car, while stopping for a few minutes in traffic                                     


                                                          TOTAL SCORE =                                

Have you had a sleep study? ________

Do you own a CPAP? ______ If so, do you use it nightly?_______


SIGNATURE:                                                                             DATE: