* Denotes required fields
Self-Assessment (Sleepiness Scale)
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First Name
M.I.
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Last Name
*
Date of Birth
(mm/dd/yyyy)
*
Gender
(Select one)
Female
Male
Body Metrics:
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Height
(feet)
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Height
(inches)
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Weight
(pounds)
*
Email
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.
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Sitting and reading
(Select one)
0 = would never doze or sleep
1 = slight chance of dozing or sleeping
2 = moderate chance of dozing or sleeping
3 = high chance of dozing or sleeping
*
Watching Television
(Select one)
0 = would never doze or sleep
1 = slight chance of dozing or sleeping
2 = moderate chance of dozing or sleeping
3 = high chance of dozing or sleeping
*
Sitting inactive in a public place
(Select one)
0 = would never doze or sleep
1 = slight chance of dozing or sleeping
2 = moderate chance of dozing or sleeping
3 = high chance of dozing or sleeping
*
Riding in a car for an hour without a break
(Select one)
0 = would never doze or sleep
1 = slight chance of dozing or sleeping
2 = moderate chance of dozing or sleeping
3 = high chance of dozing or sleeping
*
Lying down to rest in the afternoon
(Select one)
0 = would never doze or sleep
1 = slight chance of dozing or sleeping
2 = moderate chance of dozing or sleeping
3 = high chance of dozing or sleeping
*
Sitting and talking to someone
(Select one)
0 = would never doze or sleep
1 = slight chance of dozing or sleeping
2 = moderate chance of dozing or sleeping
3 = high chance of dozing or sleeping
*
Sitting quietly after lunch (with NO alcohol)
(Select one)
0 = would never doze or sleep
1 = slight chance of dozing or sleeping
2 = moderate chance of dozing or sleeping
3 = high chance of dozing or sleeping
*
In a car, while stopped in traffic
(Select one)
0 = would never doze or sleep
1 = slight chance of dozing or sleeping
2 = moderate chance of dozing or sleeping
3 = high chance of dozing or sleeping
