Sleep Survey

Instructions:
Use the following scale to choose the most appropriate number for each situation:

WOULD NEVER DOZE SLIGHT CHANCE OF DOZING MODERATE CHANCE OF DOZING HIGH CHANCE OF DOZING
0 1 2 3

All questions must be answered to receive an accurate evaluation.

Sitting and reading.
Watching TV
Sitting, inactive in a public place (i.e. theater or 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 a lunch without alcohol
In a car, while stopped for a few minutes in traffic
   

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