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.