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.