Sleep Questionnaire

1. Please describe your primary sleep problem:

2. How long have you had this problem and how did it begin?
[0-10]

3. Have you ever had a sleep study? What did it show? Study showed:

4. What time do you go to bed? [Please give a range if this varies]

5. In general, how long does it take you to fall asleep? [0-60]

6. While falling asleep do you experience:

7. If you have difficulty falling asleep, what generally disturbs your sleep?

8. During the night, do you have:



9. How many times do you wake up during the night? For what reason?
[0-10] Times Due to:

10. What time do you usually wake up? [Give range if varies]

11. Upon awakening do you experience:

12. During the day do you experience:

13. Do you nap during the day? If so, for how long?
[0-60]

14. Do you work rotating shifts?

15. Do you ever experience vivid dream-like scenes upon awakening or falling asleep?

16. When you are angry or sad or very happy, do you have sudden weakness in you arms or legs?

17. Have you ever fallen asleep while driving?

18. Do you have any of the following:


Epworth Sleepiness Scale

How likely are you to fall asleep in the following situations? This refers to your usual way of life in recent times. Even if you have not done some of these things recently, try to work out how they would have affected you. Choose only one box for each situation.

Situations Never (0) Slight (1) Moderate (2) High (3)
Sitting and reading
Watching TV
Sitting, inactive in public place (e.g. Church or meeting)
As a passenger in a car for an hour without a break
Lying down to rest in the afternoon
Sitting and talking to someone
Sitting quietly after lunch
In a car, while stopped for a few minutes

Is there any additional information we should know about your sleep disorder?