Sleep Disorder Screening

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

Your Name
Situation
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 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 cirumstances permit
0 1 2 3
Sitting and talking to someone
0 1 2 3
Sitting quietly after lunch, without alcohol
0 1 2 3
In a car, while stopped for a few minutes in traffic
0 1 2 3

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