Sleepiness Scale

& Snoring Questionnaire

Level of Daytime Sleepiness

For the following questions, please select the score that best describes your likelihood to dose off or fall asleep in the follow situations.

0 - Would never dose or sleep

1 - slight chance of dozing or sleeping

2 - Moderate chance of dozing or sleeping

3 - High chance of dozing or sleeping

Sitting and Reading *

Watching TV *

Sitting Inactive In A Public Place *

Being Passenger In A Motor Vehicle For An Hour Or More *

Lying Down In The Afternoon *

Sitting And Talking To Someone *

Sitting Quietly After Lunch (No Alcohol) *

Stopped For A Few Minutes In Traffic While Driving *

Surgical History

Select date of procedure if applicable

Tonsillectomy

Adenoidectomy

Tracheotomy

Nasal Surgery

Sinus Surgery

Uvulapalatoplasty (UPPP)

Other Surgery

Previous Treatment(s)

Have you previously been treated for snoring?

Yes

Type of Treatment

Have you ever taken part of a sleep study?

Yes

When/Where

Have you ever been diagnosed with Sleep Apnea?

Yes

When/by Whom

Have you previously been treated for Sleep Apnea?

Yes

When /Where

First Name *

Last Name *

Phone *

Email *

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