Self Assessment: Do you have a Sleep Disorder?

This sleep disorder self assessment can be used to determine your level of daytime sleepiness. If you score a 10 or higher, you may want to consider seeing a sleep specialist. Any sleep issues should also be discussed with your primary care physician.

* Denotes required fields

Self-Assessment (Sleepiness Scale)

* First Name

M.I.

* Last Name

* Date of Birth (mm/dd/yyyy)

* Gender

Body Metrics:

* Height (feet)

* Height (inches)

* Weight (pounds)

Address

City

* State Example: NY

* ZIP Code Example: 12345

Primary Phone Example: 123-123-1234 x123

Secondary Phone Example: 123-123-1234 x123

* Email

YES! I would like to receive email communications from Pella Regional.

A scale can be used to determine your level of daytime sleepiness. If you score a 10 or higher, you may want to consider seeing a sleep specialist. Any issues should also be discussed with your primary care provider.

* Sitting and reading

* Watching Television

* Sitting inactive in a public place

* Riding in a car for an hour without a break

* Lying down to rest in the afternoon

* Sitting and talking to someone

* Sitting quietly after lunch (with NO alcohol)

* In a car, while stopped in traffic

Total Score

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Self Assessment: Do you have a Sleep Disorder?

Self-Assessment (Sleepiness Scale)

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