The following questionnaire (Part 1 & 2) was
professionally developed by sleep disorder specialists
and is only the first step in evaluating you for
a possible sleep disorder. Please take a few moments
to fill out each question as accurately as possible
so that we may determine if you are a candidate
for further testing. It is sometimes helpful to
have your spouse assist you in answering some of
the questions you may not be sure about.
In contrast to just feeling tired, how likely are you to DOZE OFF or FALL ASLEEP in the following situations?
Use the scale below (0-3) to choose the most appropriate number for each situation. Even if you have not done
some of these things recently, try to work out in your mind how they might have affected you.
1. Sitting & Reading 1.
0
- Would Never Doze 1 - Slight
Chance of Dozing 2 - Moderate
Chance of Dozing 3 - High Chance
of Dozing 2. Watching
TV 2.
0 - Would Never Doze 1
- Slight Chance of Dozing 2
- Moderate Chance of Dozing 3
- High Chance of Dozing
3. Sitting inactive in a public place (i.e.
a theater) 3.
0
- Would Never Doze 1 - Slight
Chance of Dozing 2 - Moderate
Chance of Dozing 3 - High Chance
of Dozing 4. As a
car passenger for an hour without a break 4.
0
- Would Never Doze 1 - Slight
Chance of Dozing 2 - Moderate
Chance of Dozing 3 - High Chance
of Dozing 5.
Lying down to rest in the afternoon 5.
0
- Would Never Doze 1 - Slight
Chance of Dozing 2 - Moderate
Chance of Dozing 3 - High Chance
of Dozing 6. Sitting
and talking to someone 6.
0 - Would Never Doze 1
- Slight Chance of Dozing 2
- Moderate Chance of Dozing 3
- High Chance of Dozing
7. Sitting quietly after a lunch without
alcohol 7.
0 - Would Never Doze 1
- Slight Chance of Dozing 2
- Moderate Chance of Dozing 3
- High Chance of Dozing 8.
In a car, while stopping for a few minutes in traffic 8.
0
- Would Never Doze 1 - Slight
Chance of Dozing 2 - Moderate
Chance of Dozing 3 - High Chance
of Dozing
Please
choose the answer that most closely corresponds to the degree or frequency with
which you are bothered by a particular complaint or problem, especially DURING
THE LAST MONTH.
How often do you fall asleep
during the day, particularly when you are still or not busy?
1
- None or never 2 - Very slight
or rarely 3 - Slight or seldom
4 - Moderate or occasionally
5 - Major or often 6
- Great or very often 7 - Very
great or always How
great of a problem do you have with non-restorative sleep (that is, no matter
how much sleep you get, you don't wake feeling rested or restored)?
1
- None or never 2 - Very slight
or rarely 3 - Slight or seldom
4 - Moderate or occasionally
5 - Major or often 6
- Great or very often 7 - Very
great or always Do
you suffer from unexplained fatigue during the day?
1
- None or never 2 - Very slight
or rarely 3 - Slight or seldom
4 - Moderate or occasionally
5 - Major or often 6
- Great or very often 7 - Very
great or always How
often do you take a nap?
1 - None or never 2
- Very slight or rarely 3 - Slight
or seldom 4 - Moderate or
occasionally 5 - Major or often
6 - Great or very often 7
- Very great or always How
often do you drift off to sleep while driving?
1
- None or never 2 - Very slight
or rarely 3 - Slight or seldom
4 - Moderate or occasionally
5 - Major or often 6
- Great or very often 7 - Very
great or always Do
you awaken feeling really sleepy or groggy?
1
- None or never 2 - Very slight
or rarely 3 - Slight or seldom
4 - Moderate or occasionally
5 - Major or often 6
- Great or very often 7 - Very
great or always Do
you snore during sleep?
1 - None or never 2
- Very slight or rarely 3 - Slight
or seldom 4 - Moderate or
occasionally 5 - Major or often
6 - Great or very often 7
- Very great or always How
often has a bed partner noted you holding or stopping your breath during sleep?
1
- None or never 2 - Very slight
or rarely 3 - Slight or seldom
4 - Moderate or occasionally
5 - Major or often 6
- Great or very often 7 - Very
great or always How
often is your sleep disturbed by other breathing problems?
1
- None or never 2 - Very slight
or rarely 3 - Slight or seldom
4 - Moderate or occasionally
5 - Major or often 6
- Great or very often 7 - Very
great or always Do
you suffer from headaches on awakening?
1
- None or never 2 - Very slight
or rarely 3 - Slight or seldom
4 - Moderate or occasionally
5 - Major or often 6
- Great or very often 7 - Very
great or always How
often do you awaken because of heartburn or regurgitation (burning in the throat
or gagging on stomach contents?)
1
- None or never 2 - Very slight
or rarely 3 - Slight or seldom
4 - Moderate or occasionally
5 - Major or often 6
- Great or very often 7 - Very
great or always How
often is your sleep disturbed because of chest pain or angina?
1
- None or never 2 - Very slight
or rarely 3 - Slight or seldom
4 - Moderate or occasionally
5 - Major or often 6
- Great or very often 7 - Very
great or always How
great of a problem do you have getting to sleep?
1
- None or never 2 - Very slight
or rarely 3 - Slight or seldom
4 - Moderate or occasionally
5 - Major or often 6
- Great or very often 7 - Very
great or always How
great of a problem do you have waking up from sleep?
1
- None or never 2 - Very slight
or rarely 3 - Slight or seldom
4 - Moderate or occasionally
5 - Major or often 6
- Great or very often 7 - Very
great or always Do
you suffer from restless sleep?
1 - None or never 2
- Very slight or rarely 3 - Slight
or seldom 4 - Moderate or
occasionally 5 - Major or often
6 - Great or very often 7
- Very great or always How
often has a bed partner noted that your legs twitch or kick in your sleep?
1 - None or never 2
- Very slight or rarely 3 - Slight
or seldom 4 - Moderate or
occasionally 5 - Major or often
6 - Great or very often 7
- Very great or always How
often are you troubled by restless or "creepy" lets in the late evening
or at night?
1 - None or never 2
- Very slight or rarely 3 - Slight
or seldom 4 - Moderate or
occasionally 5 - Major or often
6 - Great or very often 7
- Very great or always How
often do you feel unable to move (paralyzed) when falling asleep or waking up?
1
- None or never 2 - Very slight
or rarely 3 - Slight or seldom
4 - Moderate or occasionally
5 - Major or often 6
- Great or very often 7 - Very
great or always How
often do you have dream-like images (hallucinating people or sounds in the room)
when just falling asleep or awakening, even though you know you are not asleep?
1 - None or never 2
- Very slight or rarely 3 - Slight
or seldom 4 - Moderate or
occasionally 5 - Major or often
6 - Great or very often 7
- Very great or always How
often during the day do you have episodes of sudden muscular weakness when laughing,
angry or in other emotional situations?
1
- None or never 2 - Very slight
or rarely 3 - Slight or seldom
4 - Moderate or occasionally
5 - Major or often 6
- Great or very often 7 - Very
great or always How
often do you walk in your sleep?
1 - None or never 2
- Very slight or rarely 3 - Slight
or seldom 4 - Moderate or
occasionally 5 - Major or often
6 - Great or very often 7
- Very great or always How
often do you have nightmares (frightening dreams)?
1
- None or never 2 - Very slight
or rarely 3 - Slight or seldom
4 - Moderate or occasionally
5 - Major or often 6
- Great or very often 7 - Very
great or always How
often do you awaken from sleep screaming, violent or confused?
1
- None or never 2 - Very slight
or rarely 3 - Slight or seldom
4 - Moderate or occasionally
5 - Major or often 6
- Great or very often 7 - Very
great or always How
often is your sleep disturbed by any other problems?
1
- None or never 2 - Very slight
or rarely 3 - Slight or seldom
4 - Moderate or occasionally
5 - Major or often 6
- Great or very often 7 - Very
great or always How
valuable would sleep treatment be to improving your health and well being?
1
- None or never 2 - Very slight
or rarely 3 - Slight or seldom
4 - Moderate or occasionally
5 - Major or often 6
- Great or very often 7 - Very
great or always
