Name *

First Name

Last Name

1. I feel sleepy during the day, even when I get a good night’s sleep. *

Yes

No

2. I often have difficulty focusing on work during the day. *

Yes

No

3. I often do not feel refreshed from a nap. *

Yes

No

4. I have been told that I often snore at night. *

Yes

No

5. I have been told that I my breathing pauses when sleeping. *

Yes

No

6. I have been diagnosed with sleep apnea. *

Yes

No

7. I intermittently work at night. *

Yes

No

8. I have excessive sleepiness and/or insomnia associated with a work schedule that overlaps the usual time for sleep. *

Yes

No

9. My daytime sleepiness has been present for at least three months. *

Yes

No

10. My sleepiness/ decreased focus causes significant distress or impairment in mental, physical, social, occupational, educational, or other important areas of functioning. *

Yes

No

11. My sleepiness/decreased focus is not explained by a mental disorder, medication, or substance use disorder. *

Yes

No