*** Please fill out this form in full, to the best of your knowledge

How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired?

This refers to your usual way of life in recent times.

Even if you haven't done some of these things recently, try to work out how they would have affected you.

Use the following scale to choose the most appropriate number for each situation:

0 = Never     1 = slight chance     2 = moderate chance     3 = high chance

It is important that you answer each question as best you can.           

Sitting and reading            

Watching TV

Sitting, inactive in a public place (e.g. theater or a meeting)

As a passenger in a 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 a lunch without alcohol

In a car, while stopped for a few minutes in the traffic



Thank you for your cooperation