Sleep Disorder Screening Questionnaire Name: Date: How likely are you to doze off or fall asleep in the following situations? 0 = would never doze    1 = slight chance of dozing    2 = moderate chance of dozing    3 = high chance of dozing Situation Chance of Dozing 0 1 2 3 Sitting and reading Watching TV Sitting, inactive in a public place (e.g., a theater or meeting) As a passenger in a car for an hour without a break Lying down to rest in the afternoon when cirumstances permit Sitting and talking to someone Sitting quietly after lunch, without alcohol In a car, while stopped for a few minutes in traffic Total from above Do you often feel sleepy during the daytime? Yes    No Do you snore, or has anyone ever told you that you snore? Yes    No Has anyone ever told you that you stop breathing during sleep? Yes    No Do you ever have a choking or gasping sensation during sleep? Yes    No do your legs 'kick' during sleep? Yes    No Print and Return form to your physician Printer Friendly