Many patients with chronic sleepiness cannot appreciate how sleepy they are and do not realize how impaired they may be.
You may fill this form out and print it to bring with you to your session at Wisconsin Community Mental Health
Counseling Centers or, if you prefer, this document is provided in downloadable Portable Document Format (PDF) by
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www.adobe.com. If you have any questions regarding this quiz please contact us at 262.242.3810.
Complete the following:
- Height
- Weight
- Age
- Male/ Female
Do you snore?
Yes
No
Don't Know
If you snore - your Snoring is:
slightly louder than breathing
as loud as talking
louder than talking
very loud. Can be heard in adjacent rooms
How often do you snore?
nearly every day
3-4 times a week
1-2 times a week
1-2 times a month
never or nearly never
Has your snoring ever bothered other people?
yes
no
Has anyone noticed that you quite breathing during your sleep?
nearly every day
3-4 times a week
1-2 times a week
1-2 times a month
never or nearly never
How often do you feel tired or fatigued after your sleep?
nearly every day
3-4 times a week
1-2 times a week
1-2 times a month
never or nearly never
During your wake time, do you feel tired, fatigued or not up to par?
nearly every day
3-4 times a week
1-2 times a week
1-2 times a month
never or nearly never
Have you ever nodded off or fallen asleep while driving a vehicle
yes
no
if yes, how often does it occur?
nearly every day
3-4 times a week
1-2 times a week
1-2 times a month
never or nearly never
