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Sleep Deprivation Survey
Please take your time to fill out this survey, we appreciate your time to do so. Unanswered question will be assumed as no and of the question does not apply due to being under the age of 21 or not being and to drive do not answer or simply put no.
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Specify your gender
Male
Female
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Are you in High School or College?
High School
College (either two or four year)
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Do you usually need a loud alarm clock to wake you up in the morning?
Yes
No
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Do you usually hit the snooze control to get a few minutes more of sleep when the alarm goes off in the morning (or simply turn off the alarm and try to catch a bit more sleep)?
Yes
No
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Do you find that getting out of bed in the morning is usually a struggle?
Yes
No
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Do you sometimes sleep through the alarm?
Yes
No
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Do you usually find that a single beer, glass of wine, or other alcoholic drink seems to have a noticeable effect on you?
***Do not answer if under 21***
Yes
No
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Do you sleep longer on weekends than you normally do during the week?
Yes
No
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On vacations and holidays do you sleep longer than you normally do on regular workweeks?
Yes
No
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Do you feel that your "get-up-and-go" has gotten up and gone?
Yes
No
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Do you find that it is more difficult attend to details on a routine chores than it used to be?
Yes
No
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Do you sometimes fall asleep when you had not intended to?
Yes
No
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Do you find yourself getting very sleepy while you are sitting and reading?
Yes
No
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Do you sometimes find yourself getting very sleepy or dozing off when you are watching TV?
Yes
No
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When you are a passenger in an airplane, car, bus, or train and the trip lasts over an hour without a break, do you commonly find yourself getting very sleepy or dozing off?
Yes
No
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Do you usually feel very sleepy or doze off when you are sitting quietly after a large lunch without alcohol?
Yes
No
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Do you tend to get sleepy when you are sitting quietly at a public meeting, lecture, or in a theater?
Yes
No
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Have you sometimes found yourself getting extremely sleepy with the urge to doze off when you drive and are stopped for a few minutes in traffic?
Yes
No
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Do you drink more than four (4) cups of coffee or tea (containing caffeine) during the day? (Remember to count refills; also count extra large take-out cups as two (2) cups)
Yes
No
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