Sleep Disorders Screening Questionnaire

Please check any of the following statements that are true:

1. I have been told that I snore.
 2. I have been told that I stop breathing when I sleep.
 3. I have high blood pressure.
 4. My friends and family say that I’m grumpy and irritable.
 5. I have fallen asleep while driving.
 6. I have noticed my heart pounding or beating irregularly during the night.
 7. I get morning headaches.
 8. I suddenly wake gasping for breath.
 9. I am overweight.
 10. I seem to be losing my sex drive.
 11. I often feel sleepy and struggle to remain alert.
 12. I frequently wake with a dry mouth.
 13. I have difficulty falling asleep.
 14. Thoughts race through my mind and prevent me from sleeping.
 15. I anticipate a problem with sleep several times a week.
 16. I wake up and cannot go back to sleep.
 17. I worry about things and have trouble relaxing.
 18. I wake up earlier in the morning than I would like to.
 19. I lie awake for half an hour or more before I fall asleep.
 20. When I am angry or surprised, I feel like my muscles go limp.
 21. I often feel like I am in a daze.
 22. I have experienced vivid dreamlike scenes.
 23. I have fallen asleep in social settings such as the movies or at a party.
 24. I have trouble at work because of sleepiness.
 25. I have dreams soon after falling asleep or during naps.
 26. I have “sleep attacks” during the day no matter how hard I try to stay awake.
 27. I have had episodes of feeling paralyzed during my sleep or on awakening.
 28. Other than when exercising, I still experience muscle tension in my legs.
 29. I have noticed (or others have commented) that parts of my body jerk during sleep.
 30. I have been told I kick at night.
 31. When trying to go to sleep, I experience an aching or crawling sensation in my legs.
 32. I experience leg pain and cramps at night.
 33. Sometimes I can’t keep my legs still at night. I just have to move them to feel comfortable.
 34. Even though I slept during the night, I feel sleepy during the day.

 

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Based on your answers in this informal screening tool (not to be used for diagnostic purposes) you have symptoms that may be associated with the following:

SLEEP APNEA

You answered yes to two or more questions relating to symptoms commonly associated with Sleep Apnea — which may cause you to stop breathing repeatedly during your sleep.

INSOMNIA

You answered yes to two or more questions relating to symptoms commonly associated with Insomnia — a persistent inability to fall asleep or stay asleep.

NARCOLEPSY

You answered yes to two or more questions relating to symptoms commonly associated with Narcolepsy — a life long disorder characterized by uncontrollable sleep attacks during the day.

PERIODIC LIMB MOVEMENT DISORDER OR RESTLESS LEGS SYNDROME

You answered yes to two or more questions relating to symptoms commonly associated with Periodic Limb Movement Disorder — uncontrollable leg or arm jerks during sleep or Restless Legs Syndrome – uncomfortable feelings in the legs at night.

You are not showing common symptoms associated with Sleep Apnea, Insomnia, Narcolepsy, Periodic Limb Movement Disorder or Restless Leg Syndrome. However, there are over 60 types of Sleep Disorders and if you are experiencing any symptoms that are affecting you or your bed partner's overall sleep or quality of life then we recommend that you be evaluated by one of our sleep specialists.

REMEMBER: This survey is only a general screening tool and cannot be used to rule-out a sleep disorder.

Click button below if you would like to schedule an evaluation with one of our sleep specialists to assess your symptoms.