Please indicate how likely you are to doze off or fall asleep in the following situations:
(0=never, 1=slight, 2=moderate, 3=high chance of dozing) - SELECT ONE RESPONSE FOR EACH QUESTION
Fill in the blanks, select yes or no response for each question.
Please select yes or no response for each question.
Notes: (Please insert any notes for the doctor regarding snoring, sleep patterns or sleep apnea that you feel may be appropriate.)