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 haven't done some of these things recently try to work out how they would be affected you.
It is important that you answer each question as best you can.
Sitting and reading 0 - would never doze 1 - slight chance of dozing 2 - moderate chance of dozing 3 - high chance of dozing
Watching TV 0 - would never doze 1 - slight chance of dozing 2 - moderate chance of dozing 3 - high chance of dozing
Sitting, inactive in a public place (e.g. a theater or a meeting) 0 - would never doze 1 - slight chance of dozing 2 - moderate chance of dozing 3 - high chance of dozing
As a passenger in a car for an hour without a break 0 - would never doze 1 - slight chance of dozing 2 - moderate chance of dozing 3 - high chance of dozing
Lying down to rest in the afternoon when circumstances permit 0 - would never doze 1 - slight chance of dozing 2 - moderate chance of dozing 3 - high chance of dozing
Sitting and talking to someone 0 - would never doze 1 - slight chance of dozing 2 - moderate chance of dozing 3 - high chance of dozing
Sitting quietly after a lunch without alcohol 0 - would never doze 1 - slight chance of dozing 2 - moderate chance of dozing 3 - high chance of dozing
In a car, while stopped for a few minutes in traffic 0 - would never doze 1 - slight chance of dozing 2 - moderate chance of dozing 3 - high chance of dozing
Your Initials:
Who should receive these results? Cancel Maj. Smith, LCSW Dr. Webb
Thank you for your cooperation
© M.W. Johns 1990-97