Sleep Questionnaire

Select the questionnaire you would like to fill out:

• Epworth Sleepiness Scale
• Fatigue Severity Scale (FSS)
• Berlin Questionnaire 

Epworth Sleepiness Scale

How likely are you to doze off or fall asleep in the situations described below, in contrast to feeling just tired?

This refers to your usual way of life in recent times.

Even if you haven't done some of these things recently try to work out how they would have affected you.

Name:		Date:
Your Age:		Your Sex: Male Female
Use the following scale to 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 (e.g. a theatre 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 the traffic:
Total:

Fatigue Severity Scale (FSS)

This questionnaire contains nine statements that rate the severity of your fatigue symptoms. Read each statement and select a number from 1 to 7, based on how accurately it reflects your condition during the past week and the extent to which you agree or disagree that the statement applies to you.

***A low value (e.g. 1) indicates strong disagreement with the statement, whereas a high value (e.g. 7) indicates strong agreement.

Your Name:
Date:		DOB:
During the past week, I have found that: Disagree <- 1 2 3 4 5 6 7 -> Agree
My motivation is lower when I am fatigued:
Exercise brings on my fatigue:
I am easily fatigued:
Fatigue interferes with my physical functioning:
Fatigue causes frequent problems for me:
My fatigue prevents sustained physical functioning:
Fatigue interferes with carrying out certain duties and responsibilities:
Fatigue is among my three most disabling symptoms:
Fatigue interferes with my work, family or social life:
Total:
A score of greater than 36 can be considered clinically significant and may require further evaluation by your provider.

Berlin Questionnaire (for sleep apnea)

Adapted from: Table 2 from Netzer, et al., 1999. (Netzer NC, Stoohs RA, Netzer CM, Clark K, Strohl KP. Using the Berlin Questionnaire to identify patients at risk for the sleep apnea syndrome. Ann Intern Med. 1999 Oct 5;131(7):485-91).

The questionnaire consists of 3 categories related to the risk of having sleep apnea. Patients can be classified into High Risk or Low Risk based on their responses to the individual items and their overall scores in the symptom categories.

Categories and scoring:

Category 1: items 1, 2, 3, 4, 5.

• Item 1: if ‘Yes’, assign 1 point
• Item 2: if ‘c’ or ‘d’ is the response, assign 1 point
• Item 3: if ‘a’ or ‘b’ is the response, assign 1 point
• Item 4: if ‘a’ is the response, assign 1 point
• Item 5: if ‘a’ or ‘b’ is the response, assign 2 points

Add points. Category 1 is positive if the total score is 2 or more points

Category 2: items 6, 7, 8 (item 9 should be noted separately).

• Item 6: if ‘a’ or ‘b’ is the response, assign 1 point
• Item 7: if ‘a’ or ‘b’ is the response, assign 1 point
• Item 8: if ‘a’ is the response, assign 1 point

Add points. Category 2 is positive if the total score is 2 or more points

Category 3 is positive if the answer to item 10 is ‘Yes’ OR if the BMI of the patient is greater than 30kg/m2.
(BMI must be calculated. BMI is defined as weight (kg) divided by height (m) squared, i.e., kg/m2).

High Risk: if there are 2 or more Categories where the score is positive
Low Risk: if there is only 1 or no Categories where the score is positive

Additional question: item 9 should be noted separately.

Category 1
1. Do you snore?:	--- Select One --- Yes No Don't Know

2. Your snoring is:	--- Select One --- Slightly louder than breathing As loud as talking Louder than talking Very loud - can be heard in adjacent rooms
3. How often do you snore?:	--- Select One --- Nearly every day 3-4 times a week 1-2 times a week 1-2 times a month Never or nearly never
4. Has your snoring ever bothered other people?:	--- Select One --- Yes No Don't Know
5. Has anyone noticed that you quit breathing during your sleep?:	--- Select One --- Nearly every day 3-4 times a week 1-2 times a week 1-2 times a month Never or nearly never

Category 2
6. How often do you feel tired or fatigued after your sleep?:	--- Select One --- Nearly every day 3-4 times a week 1-2 times a week 1-2 times a month Never or nearly never
7. During your waking time, do you feel tired, fatigued or not up to par?:	--- Select One --- Nearly every day 3-4 times a week 1-2 times a week 1-2 times a month Never or nearly never
8. Have you ever nodded off or fallen asleep while driving a vehicle?:	--- Select One --- Yes No

9. How often does this occur?:

--- Select One --- Nearly every day 3-4 times a week 1-2 times a week 1-2 times a month Never or nearly never

Category 3
10. Do you have high blood pressure?:	--- Select One --- Yes No Don't Know