Ear, nose and neck clinics, Huddinge and Solna

In order to better evaluate the extent to which you are affected by your inconvenience, it is important
that you complete this questionnaire and submit it in the enclosed answer text

Today's date ………………………………………

Name ..................................................................... Personal number ................................................

Occupation ..................................................................... .. Phone day time

.................................................

Length .................... Weight .................. .. BMI (to be completed by a doctor) .............. .....

Never Never Sometimes OftenAlways

1a. Do you snore when you sleep?    
b. Is snoring socially handicap?    
2. Do you have family respiratory leave when you sleep?    
3. Do you feel tired a. In the mornings?    
b. in the days?    
4. If you drive a car, do you tend to pinch at the wheel and have to stay?    
5. Do you die of accidental sleep attacks?    
6.a. Do you wake up several times during the night?    
b. Do you have trouble falling asleep when you wake up?    
7. Do you have trouble falling asleep in the evening?    
8. Do you sleep less than six hours a night?    
9. Do you feel as if you were in sleep during sleep?    
10. Do you suffer from sore throats / heartburn?    
11. Do you have anxious nasal congestion?    
12. a. Do you ever experience discomfort like numbness, tingling, tingling, Yes No
tingling, leg or arm pain  
(The discomfort may feel deep in the leg / arm and may be difficult to describe)
b. Does the inconvenience arise and is relieved of activity?  
c. Do you find it difficult to be completely quiet when the trouble occurs?  
d. Does the night and night discomfort deteriorate?  
Light moderate severe Very difficult
e. Overall, how would you like to classify these discomforts?    
How likely is it to slumber or fall asleep in the following situations, as opposed to just feeling tired? It relates to your usual
way of life lately. Even though it has not been so recently, try to figure out how it would have affected you. Tick the option
that suits you best.
Risk of falling n
asleep

How likely is it to slumber if you ... No Small Moderate Great

Sitting and reading?  0
 1
 2
 3

Is watching TV?  0
 1
 2
 3

Being inactive in public places (eg theater or a meeting)?  0

 1
 2
 3

Sitting as a passenger in a car for an hour without a break?  0

 1
 2
 3

Lying down and resting in the afternoon if circumstances allow?  0

 1
 2
 3

Sitting and talking to someone?  0

 1
 2
 3

Is it still after eating lunch (without alcohol)?  0

 1
 2
 3

Sitting in a car that stayed a few minutes in traffic?  0

 1
 2
 3

Daily Value Value (ESS score) The sum of the values for ticked boxes:

No Yes Comment (Use additional paper if required)

Do you drive?  

Are you a professional driver?   If "Yes ", what profession?

Have you been involved in  

traffic incidents due to fatigue
/ sleepiness?

Are you sick   If "Yes", for what and then when?

Are you lonely?  

Do you have high blood pressure

 
and or are you treated with
medicines?

Have you had a heart attack?   If "Yes" if so when?

 
Have you had a stroke? If "Yes" if so when?

Do you have angina?  

Do you have diabetes?   If "Yes" How are you treated with insulin, tablets
or diet?

Are you treated or checked   If "Yes ", for what?

regularly with any doctor?

Do you eat any medicines incl   If "Yes", which? Dosage? Please take a list at the
doctor's visit
sleep medications?

Do you smoke?   If "Yes", how many? .......... cigarettes / day, late

when?
 Do you ingest alcohol (beer, wine  
spirits) more are three to four
days a week?
Do you have allergic problems?   If "Yes " against what?

How do you judge your general health condition?

Very good   Fairly good   neither good nor bad  bad  very bad 

How often do you feel sleepy during the day?

Almost every day   1-2 times / week  3-5 times a week  Less than 1 g / week  Less than 1 g / month 

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