Sleep Survey
Sleep Survey
Please take a few minutes to rate the following situations to determine if you are not getting enough sleep and should consider seeking medical advice. For a printable version, click here.
Use the following scale to choose the most appropriate number for each situation:
0 - would NEVER doze
1 - SLIGHT change of dozing
2 - MODERATE chance of dozing
3 - HIGH chance of dozing
| Situation | Chance of Dozing |
| Sitting and reading | |
| Watching TV | |
| Sitting, inactive in public place (in a meeting or watching a movie) | |
| As a passenger in 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 lunch without alcohol | |
| As a driver in a car, while stopped for a few minutes in traffic | |
To schedule a sleep evaluation, call (502) 226-7691 or (888) 75-SLEEP.
This questionnaire is no substitute for a formal sleep disorders evaluation by a physician. Only your physician can diagnose a sleep disorder. If you feel you have a sleep disorder, please talk with your physician as soon as possible.