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(Created page with "==Questions== ===General=== * '''What is your occupation?''' -Please specify______________ * '''How old are you?''' ❑<25 ❑25-30 ❑31-35 ❑36-40 ❑41-45 ❑46-50 ❑51-5...") |
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* '''How old are you?''' ❑<25 ❑25-30 ❑31-35 ❑36-40 ❑41-45 ❑46-50 ❑51-55 ❑56-60 ❑>60 | * '''How old are you?''' ❑<25 ❑25-30 ❑31-35 ❑36-40 ❑41-45 ❑46-50 ❑51-55 ❑56-60 ❑>60 | ||
* '''Gender?''' ❑Male ❑Female ❑Do not wish to disclose | * '''Gender?''' ❑Male ❑Female ❑Do not wish to disclose | ||
===Work time and duration=== | |||
* '''How many hours a day do you work?''' | |||
===Sleepiness=== | ===Sleepiness=== | ||
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** '''In a car, while stopped for a few minutes in the traffic:''' ❑0 ❑1 ❑2 ❑3 | ** '''In a car, while stopped for a few minutes in the traffic:''' ❑0 ❑1 ❑2 ❑3 | ||
** ''' What was your total score:''' ❑0-10 ❑10-12 ❑12-24 | ** ''' What was your total score:''' ❑0-10 ❑10-12 ❑12-24 | ||
* '''How many near-miss accidents have you had during the past one month?''' - | * '''How many near-miss accidents have you had during the past one month?''' ❑0 ❑1-2 ❑3-4 ❑5-6 ❑>6 | ||
* '''How many times did you feel sleepy while driving during the past one month?''' ❑0 ❑1-2 ❑3-4 ❑5-6 ❑>6 | |||
* '''At what time of the day did the sleepiness occur the most while driving?'''❑5am-10am ❑10am-3pm ❑3pm-8pm ❑8pm-12am ❑12am-5am | |||
* '''In the past one month, how many times did you have to stop your car because of sleepiness while driving?''' ❑0 ❑1-2 ❑3-4 ❑5-6 ❑>6 | |||
* '''What was the primary cause of drowsiness during the past one month?''' ❑Sleep deprivation ❑Medications ❑Sleep disorder ❑Other | |||
=== Brief Medical History === | |||
* '''Do you take any medications that can cause drowsiness/sleepiness/syncope?''' ❑Yes ❑No | |||
* '''Are you diagnosed with any medical illness that can cause drowsiness/sleepiness/syncope?''' ❑Yes ❑No |
Latest revision as of 04:29, 8 August 2017
Questions
General
- What is your occupation? -Please specify______________
- How old are you? ❑<25 ❑25-30 ❑31-35 ❑36-40 ❑41-45 ❑46-50 ❑51-55 ❑56-60 ❑>60
- Gender? ❑Male ❑Female ❑Do not wish to disclose
Work time and duration
- How many hours a day do you work?
Sleepiness
- Are you diagnosed with a sleeping disorder? ❑Yes ❑No
- How likely are you to doze-off in the following situations:
(0 = would never doze 1 = slight chance of dozing 2 = moderate chance of dozing 3 = high chance of dozing)
- Watching TV: ❑0 ❑1 ❑2 ❑3
- Sitting and reading Sitting and reading: ❑0 ❑1 ❑2 ❑3
- Sitting, inactive in a public place (e.g. a theatre or a meeting): ❑0 ❑1 ❑2 ❑3
- As a passenger in a car for an hour without a break: ❑0 ❑1 ❑2 ❑3
- Lying down to rest in the afternoon when circumstances permit: ❑0 ❑1 ❑2 ❑3
- Sitting and talking to someone: ❑0 ❑1 ❑2 ❑3
- Sitting quietly after a lunch without alcohol: ❑0 ❑1 ❑2 ❑3
- In a car, while stopped for a few minutes in the traffic: ❑0 ❑1 ❑2 ❑3
- What was your total score: ❑0-10 ❑10-12 ❑12-24
- How many near-miss accidents have you had during the past one month? ❑0 ❑1-2 ❑3-4 ❑5-6 ❑>6
- How many times did you feel sleepy while driving during the past one month? ❑0 ❑1-2 ❑3-4 ❑5-6 ❑>6
- At what time of the day did the sleepiness occur the most while driving?❑5am-10am ❑10am-3pm ❑3pm-8pm ❑8pm-12am ❑12am-5am
- In the past one month, how many times did you have to stop your car because of sleepiness while driving? ❑0 ❑1-2 ❑3-4 ❑5-6 ❑>6
- What was the primary cause of drowsiness during the past one month? ❑Sleep deprivation ❑Medications ❑Sleep disorder ❑Other
Brief Medical History
- Do you take any medications that can cause drowsiness/sleepiness/syncope? ❑Yes ❑No
- Are you diagnosed with any medical illness that can cause drowsiness/sleepiness/syncope? ❑Yes ❑No