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How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? This refers to your usual way of life in recent times. Even if you have not 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

Sitting and reading
0 1 2 3

Watching TV
0 1 2 3

Sitting inactive in a public place (e.g. a theater or a 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 circumstances permit
0 1 2 3

Sitting and talking to someone
0 1 2 3

Sitting quietly after a lunch without alcohol
0 1 2 3

In a car, while stopped for a few minutes in the traffic
0 1 2 3

Section 2

Do you snore?

Yes No

If "yes" please continue with question #2
If "no" or "I don't know" please continue with #5

Your snoring is...

slightly louder than breathing
as loud as talking
louder than talking
very loud. Can be heard in adjacent rooms.

How often do you snore?

nearly every day
3-4 times a week
1-2 times a week
1-2 times a month
Never or nearly never

Has your snoring ever bothered other people?

yes
no

Has anyone noticed that you quit breathing during your sleep?

nearly every day
3-4 times a week
1-2 times a week
1-2 times a month
never or nearly never

How often do you feel tired or fatigued after your sleep?

nearly every day
3-4 times a week
1-2 times a week
1-2 times a month
never or nearly never

During your waketime, do you feel tired, fatigued or not up to par?

nearly every day
3-4 times a week
1-2 times a week
1-2 times a month
never or nearly never

Have you ever nodded off or fallen asleep while driving a vehicle?

Yes No

If yes how often does it occur?

nearly every day
3-4 times a week
1-2 times a week
1-2 times a month
never or nearly never

Do you have high blood pressure?

Yes No Don't know

10)

Is your blood pressure being treated?

Yes No

11)

Do you experience a creeping feeling in your legs?

Yes No

12)

Do you or have you ever been told that you kick your legs at night?

Yes No

13)

Your snoring is also...

frequently interrupted by pauses/choking
occasionally interrupted by pauses/choking
not interrupted as far as you know

14)

Do you snore in every body position?

Yes No I don't know

15)

Do you have, or ever had a bed partner?

Yes No

16)

Has your bed partner ever commented that you snore?

Yes, loud snoring Yes, soft snoring No

17)

If you snore, is it loud enough to bother her/him?

Yes No

18)

Has anyone besides a bed partner ever commented on your snoring (roommate, neighbor, family, etc.)?

Yes, loud snoring Yes, soft snoring No

19)

Do you wake up in the morning with headaches?

Yes No

20)

Do you wake up during the night to go to the toilet?

frequently need to get up
occasionally need to get up
rarely need to get up
never need to get up

21)

Are you a shift worker?

Yes No

22)

Do you have trouble initiating and/or maintaining sleep?

nearly every day
3 to 4 times a week
once or twice a week
once or twice a month
never or hardly ever

23)

What do you feel is your ideal amount of sleep per day?

2-4 5 6 7 8 9 10

24)

Estimate the average number of hours of sleep you had per day during the last week.

2-4 5 6 7 8 9 10

Personal Information

Title:

First name:*

Surname:

Email:*

Telephone:

Address

City

County

Postcode

Height:*

		inches
		cm

Weight:*

		pounds
		kg

Age in years *

Neck size:

inches

Gender:

Male Female

Occupation:

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