Instructions:
Fill in the blanks.
Use the scale below 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
Sitting and reading

Watching TV

Sitting, inactive in a public place (i.e. a theater or a meeting)

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 in traffic

_________

_________

_________

_________

_________

_________

_________

_________

Total Score _________

The number for the eight situations are added to give a global score between 0 and 24.
0-10 = not usually clinically significant
11-24 = Clinically significant

If you scored 10 or above, don’t be surprised if you are the one out of three American adults affected by sleep disorders and disturbances. Alarmingly, 95% of all sleep disorder cases remain undiagnosed and untreated despite the availability of effective, insured medical treatment.

Many people do not seek help because they are unaware of the nature, severity or cause of their problem. Sleep disorders can be very serious, and some are linked to congestive heart failure. Don’t suffer needlessly when help is available.