Pleases complete this form if you have been asked to by your GP.
How likely are you to doze off or fall asleep in the following situations? You should rate your chances
of dozing off, not just feeling tired. Even if you have not done some of these things recently try to
determine how they would have affected you.
Sitting inactive in a public place (eg theatre or meeting)
As a passenger in a car for an hour without a break
Lying down to rest in the afternoon
Sitting and talking to someone
Sitting quietly after a lunch without alcohol
In a car, whilst stopped for a few minutes in traffic
0-7 : It is unlikely that you are abnormally sleepy.
8-9 : You have an average amount of daytime sleepiness.
10-15 : You may be excessively sleepy depending on the situation.
16-24 : You are excessively sleepy.
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