Please mark the following answers as it applies to your sleep complaints.
I feel fatigued or sleepy:
daily 1-2 times weekly 3-4 times weekly 1-2 times monthly never
I feel rested after sleep:
almost never 1-2 times weekly 3-4 times weekly 1-2 times monthly
If sitting still, I fall asleep:
daily 1-2 times weekly 3-4 times weekly almost never
It takes longer than 30 to fall asleep:
daily 1-2 times weekly 3-4 times weekly never
I feel anxious while in bed:
On average, my total time asleep is:
1-2 hours nightly 3-4 hours nightly 5-6 hours nightly 7 or more hours nightly
Do you snore?
yes no don't know
If you snore can you be heard;
in the same room only in the next room 2 rooms away 3 rooms away next door at the neighbors
How often do you snore?
Have you been told that you quit breathing during sleep?
Do you have morning headaches?
daily 3-4 times weekly 1-2 times weekly 1-2 times monthly never
Do you have high blood pressure?
Do you use sleeping meds or alcohol?
Have you been told that your legs jerk during sleep?
Have you been told that you "act out", sleep walk or become confused during sleep?
Do you have odd crawling sensations in your legs?
Have you ever felt abrupt muscle weakness in the knees when laughing, crying or when angry?
yes no
What is your average time to go to sleep Choose Time 6AM 7AM 8AM 9AM 10AM 11AM 12AM 1PM 2PM 3PM 4PM 5PM 6PM 7PM 8PM 9PM 10PM 11PM 12AM 1AM 2AM 3AM 4AM 5AM
What is your average time to wake up Choose Time 6AM 7AM 8AM 9AM 10AM 11AM 12AM 1PM 2PM 3PM 4PM 5PM 6PM 7PM 8PM 9PM 10PM 11PM 12AM 1AM 2AM 3AM 4AM 5AM
What do you believe is the cause of your complaints?
