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Sleep Disorder Questionnaire

Please indicate if you have any of the following symptoms and with what frequency such symptoms occur using the numbered scale below:

  • 0 - Rarely/None
  • 1 - Some of the Time
  • 2 - Frequently or Part of the Time
  • 3 - Most of the Time
Sleep Apnea:
  • I am sleepy during the day though I have slept through the night.
  • I am tired during the day though I have slept through the night.
  • I fall asleep when watching TV no matter how hard I try to stay awake.
  • I have difficulty remaining alert in boring situations.
  • I have fallen asleep during routine situations.
  • I require a nap to remain awake during the evening.
  • I fall asleep when I drive.
  • I awaken during the night needing to urinate.
  • I sweat at night while asleep without being hot.
  • I often sleep better when reclining or not sleeping flat.
  • I experience swelling in my ankles, feet or hands before bed.
  • I awaken in the morning with headaches.
  • I find it difficult to lose weight through dieting.
  • I am hoarse in the morning when I awaken.
  • I have been told that I snore loudly when sleeping on my side.
  • I have been told that I snore loudly when sleeping on my back.
  • I have been told that I “stop breathing” at night.
  • I wake up “gasping” for breath.
Restless Leg Syndrome:
  • I kick or twitch my legs at night prior to falling asleep.
  • I cannot keep my legs still at night when I am relaxed.
  • I have “achy or crawling” sensations in my legs at night.

For further evaluation for Restless Leg Syndrome, click here to download our Restless Leg Syndrome questionnaire.

Insomnia:
  • I wake up at night and cannot go back to sleep no matter how hard I try.
  • I lie awake for half-hour or more before I fall asleep.
  • No matter how hard I try, I cannot shut my mind off
Narcolepsy:
  • When I am angry, surprised, or laugh, I feel like I am going to faint or “blackout."
  • I have had difficulty remaining awake during the day since I was a teenager.
  • I experience vivid, life-like scenes when I am very tired.
  • I awaken and cannot move.
  • I have blacked out or fainted for no apparent reason.
Bruxing/TMJ:
  • I have been told I grind or clench my teeth when sleeping.
  • I experience jaw clicking, locking and pain.
  • I experience muscle twitching or soreness in my face.
  • I experience dizziness, tinnitus or ringing in my ears.

If you answer 1, 2 or 3 on any of the questions above, contact your physician for possible Obstructive Sleep Apnea (OSA), Narcolepsy, Insomnia or bruxing/TMJ.