FOSQ-10 Questionnaire

FOSQ-10 Questionnaire

Please complete all sections as accurately as possible
First Name*
Middle Name
Last Name*
Date of Birth*

DayMonthYear
Are you currently using a prescribed therapy for a sleeping disorder?

YesNo
Please select the therapies you are currently using (select more than one if applicable)

CPAP/APAP TherapyASV TherapyBi-Level (NIV) TherapyNightshift Positional TherapyLight TherapyMandibular advancement splintOther
How long have you been using the above mentioned therapy?
FOSQ-10 Questionnaire:

Please complete all questions by selecting the most accurate response from the dropdown list.
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 operating a motor vehicle for short distances (less than 100 miles) because you become sleepy or tired?*
Do you have difficulty operating a motor vehicle for long distances (greater than 100miles) because you become sleepy or tired?*
Do you have difficulty visiting your friends of family in their home because you become sleepy or tired ?*
Has your relationship with family, friends or work colleagues been affected because you are sleepy or tired?*
Do you have difficulty watching a movie or video because you become sleepy or tired?*
Do you have difficulty being as active as you want to be in the evening because you are sleepy or tired?*
Do you have difficulty being as active as you want to be in the morning because you are sleepy or tired?*
Has your mood been affected because you are sleepy or tired?*
Activity Level Score
Vigilance Score
Intimacy Score
Productivity Score
Social Score
FOSQ-10 Total Score
FOSQ-10 Sub-Scale Score
Should be Empty:

FOSQ-10 Questionnaire

FOSQ-10 Questionnaire: