Pre-Assessment Questionnaire

Use the following scale to assign the most appropriate number for each situation listed.

Sleepiness Score
0 = Would Never Doze; 1 = Slight Chance of Dozing; 2 = Moderate Chance of Dozing; 3 = High Chance of Dozing

Situation and Chance of Dozing
1. Sitting and Reading  _______
2. Watching Television _______
3. Sitting, inactive in a public place (i.e. theater, meeting) _______
4. As a passenger in a car for an hour without a break  _______
5. Lying down to rest in the afternoon if circumstances permit _______
6. Sitting and talking with someone _______
7. Sitting quietly after lunch without alcohol _______
8. In a car, while stopped for a few minutes in traffic _______

Total _______

Normal Range 0-6; Mild Sleepiness 7-10; Moderate Sleepiness 11-16; Severe Sleepiness 17+