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Adult Registration Form B

Step 1 of 4

MM slash DD slash YYYY
Patient Name(Required)
Birth Date(Required)


How likely are you to doze off or fall asleep in the following situations, in contrast to just feeling 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. Use the following scale to choose the most appropriate number for each situation.
Sitting and Reading(Required)
Watching Television(Required)
Sitting inactive in a public place (theatre/meeting)(Required)
As a passenger in a car for an hour without a break(Required)
Lying down to rest in the afternoon(Required)
Sitting and talking to someone(Required)
Sitting quietly after lunch (with no alcohol)(Required)
In a car, while stopped in traffic(Required)

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