Sleep Screening Questionnaire - RG Header Image

Sleep Screening Questionnaire

How likely are you to doze off or fall asleep in the situations listed 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 out how they would have affected you.

Date of Birth:

Use the following scale to choose the most appropriate number for each situation:

0 = I would never doze___________ 2 = I have a moderate change of dozing
1 = I have a slight chance of dozing ___________3 = I have a high chance of dozing


1. Sitting and reading
2. Watching TV
3. Sitting inactive in a public place (e.g. a theatre or a meeting)
4. As a passenger in a car for an hour without a break
5. Lying down to rest in the afternoon when circumstances permit
6. Sitting and talking to someone
7. Sitting quietly after lunch without alcohol
8. In a car while stopped for a few minutes in traffic
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