Please enable JavaScript in your browser to complete this form.Sleepiness ScaleLayoutName *Date *Age *Sex *MaleFemaleLayoutS: Do you snore loudly (louder than talking or loud enough to be heard through closed doors)? Yes/NoYESNoLayoutT: Do you often feel tired, fatigued or sleep during the day? Yes/NoYESNoLayoutO: Has anyone observed you not breathing during sleep? Yes/NoYESNoLayoutP: Do you have or have you been treated for high blood pressure? Yes/NoYESNoYou have a high risk of sleep apnea if you answered ‘yes’ to two or more of these questions.LayoutB: Is your Body Mass Index more than 35kg/m2? HeightWeight= BMI Yes/NoYESNoLayoutA: Is your age more than 50 years old? Yes/NoYESNoLayoutN: Is your neck circumference greater than 40 cm/16 inches? Yes/NoYESNoLayoutG: Is your gender male? Yes/NoYESNoYou have a high risk of sleep apnea if you answered ‘yes’ to three or more of the eight questions.How likely are you to feel tired or fatigued in the situations described below, 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 how they would have affected you.Use the following scale to choose the most appropriate number for each situation:0 = would never doze1 = slight chance of dozing2 = moderate chance of dozing3 = high chance of dozingSituationLayoutSitting and readingChance of feeling tired/fatiguedLayoutWatching TVChance of feeling tired/fatiguedLayoutSitting, inactive in a public place (e.g. a theatre or a meeting)Chance of feeling tired/fatiguedLayoutAs a passenger in a car for an hour without breakChance of feeling tired/fatiguedLayoutLying down to rest in the afternoon if circumstances permitChance of feeling tired/fatiguedLayoutSitting and talking to someoneChance of feeling tired/fatiguedLayoutSitting quietly after lunch without alcoholChance of feeling tired/fatiguedLayoutIn a car, while stopped for a few minutes in trafficChance of feeling tired/fatiguedLayoutTOTAL=Chance of feeling tired/fatiguedSCORE: 0-10 NORMAL RANGE10-12 BORDERLINE12-24 ABNORMALSubmit
