canyonviewent.com - FOSQ Form

FUNCTIONAL OUTCOMES OF SLEEP QUESTIONNAIRE

(FOSQ)
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.

DIRECTIONS: Select only one answer for each question. Please try to be as accurate as possible. All information will be kept confidential.
General Productivity
1. Do you have difficulty concentrating on the things you do because you are sleepy or tired?

I don't do this activity for other reasonsNo difficultyYes a little difficultyYes a moderate difficultyYes a extreme difficulty
2. Do you generally have difficulty remembering things, because you are sleepy or tired?

I don't do this activity for other reasonsNo difficultyYes a little difficultyYes a moderate difficultyYes a extreme difficulty
Activity Level
3. Has your relationship with family, friends or work colleagues been affected because you are sleepy or tired?

I don't do this activity for other reasonsNo difficultyYes a little difficultyYes a moderate difficultyYes a extreme difficulty
4. Do you have difficulty being as active as you want to be in the morning because you are sleepy or tired?

I don't do this activity for other reasonsNo difficultyYes a little difficultyYes a moderate difficultyYes a extreme difficulty
5. Do you have difficulty being as active as you want to be in the evening because you are sleepy or tired?

I don't do this activity for other reasonsNo difficultyYes a little difficultyYes a moderate difficultyYes a extreme difficulty
Vigilance
6. Do you have difficulty operating a motor vehicle for short distances (less than 100 miles) because you become sleepy or tired?

I don't do this activity for other reasonsNo difficultyYes a little difficultyYes a moderate difficultyYes a extreme difficulty
7. Do you have difficulty operating a motor vehicle for long distances (greater than 100 miles) because you become sleepy or tired?

I don't do this activity for other reasonsNo difficultyYes a little difficultyYes a moderate difficultyYes a extreme difficulty
8. Do you have difficulty watching a movie or videotape because you become sleepy or tired?

I don't do this activity for other reasonsNo difficultyYes a little difficultyYes a moderate difficultyYes a extreme difficulty
Social Outcomes
9. Do you have difficulty visiting with your family or friends in their home because you become sleepy or tired?

I don't do this activity for other reasonsNo difficultyYes a little difficultyYes a moderate difficultyYes a extreme difficulty
Intimacy & Sexual Relationships
10. Has your desire for intimacy or sex been affected because you are sleepy or tired?

I don't engage in sexual activity for other reasonsNoYes, a littleYes, moderatelyYes, extremely
Thank you for completing this questionnaire.
Should be Empty:

FUNCTIONAL OUTCOMES OF SLEEP QUESTIONNAIRE

General Productivity

Activity Level

Vigilance

Social Outcomes

Intimacy & Sexual Relationships