Measuring Sleepiness and its Connection to Sleep Apnea

Please answer the following questions to determine your “sleepiness”.

Name

First

Last

Mobile Phone #

How likely are you to doze off or fall asleep in the following situations?

	0=Would never fall asleep	1=Slight chance of falling asleep	2=Moderate chance of falling asleep	3=High chance of falling asleep
Sitting and reading	0=Would never fall asleepSitting and reading 0=Would never fall asleep	1=Slight chance of falling asleepSitting and reading 1=Slight chance of falling asleep	2=Moderate chance of falling asleepSitting and reading 2=Moderate chance of falling asleep	3=High chance of falling asleepSitting and reading 3=High chance of falling asleep
Watching TV	0=Would never fall asleepWatching TV 0=Would never fall asleep	1=Slight chance of falling asleepWatching TV 1=Slight chance of falling asleep	2=Moderate chance of falling asleepWatching TV 2=Moderate chance of falling asleep	3=High chance of falling asleepWatching TV 3=High chance of falling asleep
Sitting inactive, in a public place (eg, a theater or meeting)	0=Would never fall asleepSitting inactive, in a public place (eg, a theater or meeting) 0=Would never fall asleep	1=Slight chance of falling asleepSitting inactive, in a public place (eg, a theater or meeting) 1=Slight chance of falling asleep	2=Moderate chance of falling asleepSitting inactive, in a public place (eg, a theater or meeting) 2=Moderate chance of falling asleep	3=High chance of falling asleepSitting inactive, in a public place (eg, a theater or meeting) 3=High chance of falling asleep
As a passenger in a car, for an hour or more without a break	0=Would never fall asleepAs a passenger in a car, for an hour or more without a break 0=Would never fall asleep	1=Slight chance of falling asleepAs a passenger in a car, for an hour or more without a break 1=Slight chance of falling asleep	2=Moderate chance of falling asleepAs a passenger in a car, for an hour or more without a break 2=Moderate chance of falling asleep	3=High chance of falling asleepAs a passenger in a car, for an hour or more without a break 3=High chance of falling asleep
Lying down to rest in the afternoon, when circumstances permit	0=Would never fall asleepLying down to rest in the afternoon, when circumstances permit 0=Would never fall asleep	1=Slight chance of falling asleepLying down to rest in the afternoon, when circumstances permit 1=Slight chance of falling asleep	2=Moderate chance of falling asleepLying down to rest in the afternoon, when circumstances permit 2=Moderate chance of falling asleep	3=High chance of falling asleepLying down to rest in the afternoon, when circumstances permit 3=High chance of falling asleep
Sitting and talking to someone	0=Would never fall asleepSitting and talking to someone 0=Would never fall asleep	1=Slight chance of falling asleepSitting and talking to someone 1=Slight chance of falling asleep	2=Moderate chance of falling asleepSitting and talking to someone 2=Moderate chance of falling asleep	3=High chance of falling asleepSitting and talking to someone 3=High chance of falling asleep
Sitting quietly after lunch without alcohol	0=Would never fall asleepSitting quietly after lunch without alcohol 0=Would never fall asleep	1=Slight chance of falling asleepSitting quietly after lunch without alcohol 1=Slight chance of falling asleep	2=Moderate chance of falling asleepSitting quietly after lunch without alcohol 2=Moderate chance of falling asleep	3=High chance of falling asleepSitting quietly after lunch without alcohol 3=High chance of falling asleep
In a car, while stopped for a few minutes in traffic	0=Would never fall asleepIn a car, while stopped for a few minutes in traffic 0=Would never fall asleep	1=Slight chance of falling asleepIn a car, while stopped for a few minutes in traffic 1=Slight chance of falling asleep	2=Moderate chance of falling asleepIn a car, while stopped for a few minutes in traffic 2=Moderate chance of falling asleep	3=High chance of falling asleepIn a car, while stopped for a few minutes in traffic 3=High chance of falling asleep

Email submit and

Add up your points to get your total score. ***A score of 10 or greater indicates daytime sleepiness, and should be addressed. Enter score below and submit to Dr. Hughes.