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ASSESSMENT FOR
SLEEP AND FATIGUE

Date of birth
Day
Month
Year
Gender
Male
Female

General information

Effects

How concerned are you with how your sleep affects your physical health?
Not concerned
Indifferent
Neutral
Concerned
Very concerned
How concerned are you with how your sleep affects your mental health?
Not concerned
Indifferent
Neutral
Concerned
Very concerned
How concerned are you with how your sleep affects your job performance?
Not concerned
Indifferent
Neutral
Concerned
Very concerned
How concerned are you with how your sleep affects your family life?
Not concerned
Indifferent
Neutral
Concerned
Very concerned
How frequently do you get enough sleep to feel fully rested and at your best the following day?
Not concerned
Indifferent
Neutral
Concerned
Very concerned

Sleep quantity

During the week, approximately how many hours of sleep would you get each day?
1-4 hours
4-6 hours
6-8 hours
8-10 hours
10-12 hours

Sleep quality

How would you rate the quality of sleep that you are getting?
Very poor
Poor
Fair
Good
Very good

Sleep disorder screening

Have you been told you snore?
Yes
No
Have you been told you hold your breath at night while sleeping?
Yes
No
Do you wake gasping for breath?
Yes
No
Do you wake with a dry mouth or have frequent sore throats?
Yes
No
Do you get heart burn or acid reflux?
Yes
No
Do you have high blood pressure?
Yes
No
Do you wake in the morning with headaches?
Yes
No
Do you wake up during the night and have trouble going back to sleep?
Yes
No
Do you have episodes of feeling paralysed during your sleep?
Yes
No
When you are angry or surprised do your sometimes feel as though your muscles go limp?
Yes
No
Have you been told you kick or jerk during your sleep or you need to move your legs to get them comfortable?
Yes
No
Do you experience an aching or crawling sensation in your legs when trying to sleep?
Yes
No
Do you have vivid dreams soon after falling asleep or during naps?
Yes
No
Have you ever been told or been aware that you sleep walk?
Yes
No
Do you grind your teeth at night or wake with an aching jaw?
Yes
No
Do you have a family history with sleep disorders?
Yes
No

Sleep latency

How long does it normally take you to fall asleep after lights out?
0-5 minutes
10-20 minutes
30-35 minutes
40-45 minutes
> 45 minutes

Nocturnal arousals

On average, how many times do you wake up at night?
0 times
1-2 times
3-4 times
5-6 times
> 6 times
Do you know what it is that is waking you?
Bathroom
Child
Pet
Pain
Unknown
Other
Do you wake naturally or with an alarm?
Natural
Alarm

Epworth Sleepiness Scale (ESS)

This scale indicates how you feel during current daily life situations.


What is the chance of you dozing off in the situations below:

While sitting and reading?
Never
Slight
Moderate
High
While watching TV?
Never
Slight
Moderate
High
While sitting inactive in a public place?
Never
Slight
Moderate
High
As a passenger in a car for an hour without a break?
Never
Slight
Moderate
High
While sitting and talking to someone?
Never
Slight
Moderate
High
While sitting quietly after lunch (without alcohol)?
Never
Slight
Moderate
High
While driving a vehicle and you have to stop for a few minutes in traffic?
Never
Slight
Moderate
High
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