A Dozing Questionnaire - For You and Your Bed Partner - Sleep Well
How likely are you or your partner to doze off or fall asleep in the following situations, in contrast to just feeling tired?
This refers to daily life in recent times, if these things have not occurred recently, try to work out how they would have affected your partner.
Use the following scale and choose the most appropriate number for each situation:
0 = Would never doze
1 = Slight chance of dozing
2 = Moderate chance of dozing
3 = High chance of dozing
Sitting and reading ____
Watching TV ____
Sitting inactive in a public place (ex. theater or a meeting) ____
As a passenger in a car for an hour without a break ____
Lying down to rest in the afternoon when circumstances permit ____
Sitting and talking to someone ____
Sitting quietly after a lunch without alcohol ____
In a car, while stopped for a few minutes in traffic ____
If you or your partner have a total score resulting in 4 or above please come into our clinic and we will provide a complimentary consultation. You or your partner may be exhibiting signs of snoring or sleep apnea both affecting your requirement for a sound sleep and possibly a profound effect on your health. We can provide an oral appliance to help prevent both snoring and/or sleep apnea from occurring.
Introducing the new sound of sleep…SILENCE!