Please enter your name: *


Phone Number: *

Gender: *

Age: *

Height: *

Weight: *

How likely are you to doze off or fall asleep in the situations described in the box below, in contrast to just feeling tired? (This refers to your usual way of life in recent times. Even if you a haven't done some of these things recently, think about 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

Situation *
0 1 2 3
Sitting and Reading
Watching TV
Sitting Inactive in a public place
As a passenger in a 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 a lunch without alcohol
In a car, while stopped for a few minutes