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3703 Camino Del Rio South
Suite 200
San Diego, CA 92108
AmeriSleep Building

Sleep Questionnaire

Answer the questions below about how likely you are to doze off or fall asleep in the following situations, in contrast to just feeling tired? Even if you have not done some of these things recently, try to imagine how they would have affected you.

Select the answer that best represents your likeliness of dozing off in the following situations: None Slight Chance Moderate Chance High Chance
Sitting and reading
Watching TV
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 lunch without alcohol
In a car, while stopped for a few minutes in traffic
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Disclaimer: AmeriSleep presents this tool as an educational service. AmeriSleep does not dispense individual medical advice, nor is this assessment tool a substitute for medical examination by a licensed physician. The assessment tool may only indicate the possibility of a sleep related breathing disorder, but does not constitute diagnosis. For diagnosis and treatment a physician should be sought if a medical problem is suspected. All results are strictly confidential and will only be used for the educational purposes for which they were intended.