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Name___________________________
Date____________________________ Age___________
Sex: M F
How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? This refers to your standard way of life in recent times. Even if you have 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
| Situation |
Chance of Dozing |
| Sitting and reading |
______ |
| Watching TV |
______ |
| Sitting inactive in a public place, (e.g. theater or a meeting) |
______ |
| As a passenger in a car for an hour without a break |
______ |
| Lying down to rest in the afternoon when circumstances permit |
______ |
| Sitting and talking to someone |
______ |
| Sitting quietly after lunch without alcohol |
______ |
| In a car, while stopped for a few minutes in traffic |
______ |
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