Please take a few minutes to rate the following situations to determine if you are not getting enough sleep and should consider seeking medical advice.

How likely are you to doze off or fall asleep in the following situations? Even if you have not done some of these things recently try to estimate the effect it might have on your level of drowsiness.

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

0 - would NEVER doze
1 - SLIGHT change of dozing
2 - MODERATE chance of dozing
3 - HIGH chance of dozing

Situation Chance of Dozing
Sitting and reading _____
Watching TV _____
Sitting, inactive in public place (in a meeting or watching a movie) _____
As a passenger in 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 _____
As a driver in a car, while stopped for a few minutes in traffic _____
Total: _______________

If your total score is 8 or less, you have an average amount of sleepiness. If your total score is 9 or more, you may be excessively sleepy and should consider seeking medical advice.

To schedule a sleep evaluation, call (502) 226-7691 or (888) 75-SLEEP.

This questionnaire is no substitute for a formal sleep disorders evaluation by a physician. Only your physician can diagnose a sleep disorder. If you feel you have a sleep disorder, please talk with your physician as soon as possible.