Full Name
Date
Your age
Your weight in kilograms
Your height (cm)
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 have not done some of the things recently, try to work out how they would have
affected you.
Situation
My chance of dozing whilst sitting and reading
My chance of dozing whilst watching TV
My chance of dozing whilst sitting, inactive in a public place ( e.g. a theatre or a meeting)
My chance of dozing as a passenger in a car for an hour without a break
My chance of dozing lying down to rest in the afternoon when circumstances permit
My chance of dozing whilst sitting and talking to someone
My chance of dozing sitting quietly after a lunch without alcohol
My chance of dozing in a car, while stopped for a few minutes in the traffic
TOTAL
OSA 50 SCREENING QUESTIONNAIRE
Overall weight
Snoring
Apneas
Age
TOTAL SCORE
How often do you snore?
How long do you snore?
How audible is your snoring (with the door shut)?
TOTAL
Functional Outcome of Sleep Questionnaire
Instructions
Some people have difficulty performing everyday activities when they feel
tired or sleepy. The purpose of this questionnaire is to find out if you generally
have difficulty carrying out certain activities because you are too sleepy or
tired.
In this questionnaire, when the words "sleepy" or "tired" are used, it means the
feeling that you can't keep your eyes open, your head is droopy, that you
want to "nod off", or that you feel the urge to take a nap. These words do not
refer to the tired or fatigued feeling you may have after you have exercised.
Do you have difficulty concentrating on the things you do because you are sleepy or tired?
Do you generally have difficulty remembering things, because you are sleepy or tired?
Do you have difficulty finishing a meal because you become sleepy or tired?
Do you have difficulty working on a hobby (for example, sewing, collecting, gardening) because you are sleepy or tired?
Do you have difficulty doing work around the house (for example, cleaning house, doing laundry, taking out the trash, repair work) because you are sleepy or tired?
Do you have difficulty operating a motor vehicle for short distances (less than 150km) because you become sleepy or tired?
Do you have difficulty operating a motor vehicle for long distances (greater than 150km) because you become sleepy or tired?
Do you have difficulty getting things done because you are too sleepy or tired to drive or take public transportation?
Do you have difficulty taking care of financial affairs and doing paperwork (for example, writing checks, paying bills, keeping financial records, filling out tax forms, etc.) because you are sleepy or tired?
Do you have difficulty performing employed or volunteer work because you are sleepy or tired?
TOTAL
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