Rate your chance of dozing during each of the following activities, according to the following scale. Keep track of your score!

0 = would never doze
1 = slight chance
2 = moderate chance
3 = high chance

Hint: Ask your spouse, lover, or good friend to help you fill out this form.

1. Sitting and reading
2. Watching TV
3. Sitting, inactive in a public place (for example, theatre or meeting)
4. As a passenger in a car for an hour without a break
5. Lying down to rest in the afternoon
6. Sitting and talking to someone
7. Sitting quietly after lunch (when you’ve had no alcohol)
8. In a car while stopped in traffic

Scores of 17 (+/- 2 points) are associated with Narcolepsy and Central Nervous System Hypersomnolence.

Scores of 11 (+/- 2 points) are associated with obstructive sleep apnea.

Scores of 9 (+/- 2 points) are associated with periodic limb movements in sleep.

Scores of 6 (+/- 2 points) are associated with primary snoring.

Scores of 2 (+/- 2 points) are associated with insomnia.

If you feel that you or a loved one suffers from a sleep disorder, visit the American Academy of Sleep Medicine website at http://www.sleepcenters.org/ to locate a sleep center near you!