/clinical/,/clinical/cckm-tools/,/clinical/cckm-tools/content/,/clinical/cckm-tools/content/questionnaires/,

/clinical/cckm-tools/content/questionnaires/name-97229-en.cckm

201605147

page

100

UWHC,UWMF,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Questionnaires

Functional Outcomes of Sleep (FOSQ)

Functional Outcomes of Sleep (FOSQ) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Questionnaires


Site: ____________________________________ ID #: _______________________________
Technician: ______________________________ Date of Data Entry: ____________________
Trial: ___________________________________

Name: _________________________________ Date: _______________________________


©Weaver, June, 2004 fosq.97 updated 6/04
Functional Outcomes of Sleep Questionnaire (FOSQ ) short Page 1


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: Please put a (_) in the box for your answer to each question. Select only one
answer for each question. Please try to be as accurate as possible. All information will be kept
confidential.




(0)
I don’t do
this
activity
for other
reasons

(4)
No
difficulty

(3)
Yes,
a little
difficulty

(2)
Yes,
moderate
difficulty

(1)
Yes,
extreme
difficulty

1. Do you have difficulty concentrating on the
things you do because you are sleepy or tired?



ˆ

ˆ

ˆ

ˆ

2. Do you generally have difficulty
remembering things, because you are sleepy or
tired?




ˆ

ˆ

ˆ

ˆ

3. Do you have difficulty operating a motor
vehicle for short distances (less than 100 miles)
because you become sleepy or tired?

ˆ

ˆ

ˆ

ˆ

ˆ

4. Do you have difficulty operating a motor
vehicle for long distances (greater than 100
miles) because you become sleepy or tired?

ˆ

ˆ

ˆ

ˆ

ˆ

Site: ____________________________________ ID #: _______________________________
Technician: ______________________________ Date of Data Entry: ____________________
Trial: ___________________________________

Name: _________________________________ Date: _______________________________


©Weaver, June, 2004 fosq.97 updated 6/04
Functional Outcomes of Sleep Questionnaire (FOSQ ) short Page 2











(0)
I don’t do
this
activity
for other
reasons

(4)
No
difficulty

(3)
Yes,
a little
difficulty

(2)
Yes,
moderate
difficulty

(1)
Yes,
extreme
difficulty

5. Do you have difficulty visiting with your
family or friends in their home because you
become sleepy or tired?

ˆ

ˆ

ˆ

ˆ

ˆ

6. Has your relationship with family, friends
or work colleagues been affected because you are
sleepy or tired?

ˆ

ˆ

ˆ

ˆ



7. Do you have difficulty watching a movie
or videotape because you become sleepy or tired?

ˆ

ˆ

ˆ

ˆ

ˆ

8. Do you have difficulty being as active as
you want to be in the evening because you are
sleepy or tired?



ˆ

ˆ

ˆ

ˆ

9. Do you have difficulty being as
active as you want to be in the morning because
ou are sleepy or tired? y




ˆ

ˆ

ˆ

ˆ


(0)
I don’t
engage in
sexual
activity
for other
reasons

(4)
No

(3)
Yes,
a
little

(2)
Yes,
moderately

(1)
Yes,
extremel
y


10. Has your desire for intimacy or sex
been affected because you are sleepy or tired?

ˆ

ˆ

ˆ

ˆ

ˆ


Thank you for completing this questionnaire.