Cannot-Sleep.com brought to you by West Georgia Sleep Disorders Center and Neurology Associates

I feel fatigued or sleepy:	Daily 1-2 times weekly 3-4 times weekly 1-2 time monthly Never
I feel rested after sleep:	Almost never 1-2 times weekly 3-4 times weekly 1-2 time 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:	Daily 1-2 times weekly 3-4 times weekly Never
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
How often do you snore?	Daily 1-2 times weekly 3-4 times weekly Never
Have you been told that you quit breathing during sleep?	Daily 1-2 times weekly 3-4 times weekly 1-2 times monthly Never
Do you have morning headaches?	Daily 1-2 times weekly 3-4 times weekly 1-2 times monthly Never
Do you have high blood pressure?	Yes No Don't know
Do you use sleeping meds or alcohol?	Daily 1-2 times weekly 3-4 times weekly 1-2 times monthly Never
Have you been told that your legs jerk during sleep?	Daily 1-2 times weekly 3-4 times weekly 1-2 times monthly Never
Have you been told that you "act out", sleep walk or become confused during sleep?	Yes No Don't know
Do you have odd crawling sensations in your legs?	Daily 1-2 times weekly 3-4 times weekly 1-2 times monthly Never
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 (please enter time, am or pm)
What is your average time to wake up (please enter time, am or pm)
What do you believe is the cause of your complaints?
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