In contrast to feeling just tired, how likely are you to doze off or fall asleep in the following situations?

Complete all of the questions even if you have not done some of these things recently.

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

1. Sitting and reading? ___                                                                      
2. Watching TV? ___                                                                                 
3. Sitting, inactive in a public? ___
4. A passenger in a car for an hour without a break ? ___                 
5. Lying down to rest in the afternoon? ___                                           
6. Sitting and talking to someone ? ___                                                 
7. Sitting quiet after lunch without alcohol? ___                                  
8. In a car, while stopped for a few minutes in traffic? ___                  
    

· 8 – 10 Mild Sleepiness
· 11 – 15 Moderate Sleepiness
· > 16 Severe Sleepiness

Talk with your health care provider about your results or call the Fairview Northland Sleep Studies Center for more information 763-389- 6420.