Herndon Family Medicine
555 Herndon Parkway, Suite 100
Herndon, VA 20170
Telephone: 703-481-1505
Fax: 703-742-8793
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Sleep Assessment Tool
Call our office at 703-481-1505 and schedule an asspointment to go over your results.
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How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? This refers to your usual way of life in recent times. Even if you have not done some of these things recently try to work out how they would have affected you.
Full Name:
Date of Birth:
While reading there is ...
No chance of dozing
Slight chance of dozing
Moderate chance of dozing
High chance of dozing
While watching TV there is ...
No chance of dozing
Slight chance of dozing
Moderate chance of dozing
High chance of dozing
While sitting inactively in public (e.g., in a theater or meeting) ...
No chance of dozing
Slight chance of dozing
Moderate chance of dozing
High chance of dozing
As a car passenger for an hour or longer ...
No chance of dozing
Slight chance of dozing
Moderate chance of dozing
High chance of dozing
While lying down to rest when circumstances permit ...
No chance of dozing
Slight chance of dozing
Moderate chance of dozing
High chance of dozing
While sitting and talking with someone ...
No chance of dozing
Slight chance of dozing
Moderate chance of dozing
High chance of dozing
While sitting quietly after lunch (without having alcoholic beverages) ...
No chance of dozing
Slight chance of dozing
Moderate chance of dozing
High chance of dozing
In a car, while stopped for a few mintues in traffic ...
No chance of dozing
Slight chance of dozing
Moderate chance of dozing
High chance of dozing
Press the button for your score ...
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555 Herndon Parkway, Suite 100, Herndon, VA 20170
Telephone: 703-481-1505 | Fax: 703-742-8793 | Email:
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