Sleep Questionnaire Click here to download a PDF of our sleep questionnaire or fill out the online form below. "*" indicates required fields Date MM slash DD slash YYYY Name* First Last Date of Birth*Age*Family Physician*Height*Weight*Briefly describe your sleep problem*How long have you had this problem?Are you a shift worker?* Yes No If you are a shift worker, please describe your shift(s)What time do you usually try to go to bed? (AM / PM)*Earliest time you go to bed? (AM / PM)*Latest time you go to bed? (AM / PM)*On average, how long does it typically take you to fall asleep? (MIN / HR)*When falling asleep, do you experience the following?(CHECK ONE BOX FOR EACH STATEMENT)Have thoughts racing through your mind?* Never Sometimes Often Feel sad or depressed?* Never Sometimes Often Have anxiety (worry about things)?* Never Sometimes Often Feel muscular tension?* Never Sometimes Often Feel afraid of not being able to sleep?* Never Sometimes Often Feel like you’re unable to move?* Never Sometimes Often Have creeping, crawling, or aching feelings in your legs? (feel like you have to move them)* Never Sometimes Often Have vivid, dream-like scenes even though you know you are not totally asleep?* Never Sometimes Often Have any kind of pain or discomfort?* Never Sometimes Often Feel afraid of the dark or anything else?* Never Sometimes Often How many times do you usually awaken at night?How long might you be awake each time?If you awaken during the night, is it usually during the:* First half of the sleep period Second half of the sleep period Both, or no particular pattern While you sleep, how often do you....? (CHECK ONE FOR EACH STATEMENT)Snore loudly?*(Please have your bed partner help you answer) Never Sometimes Often Have pauses in your breathing (apnea) while asleep?*(Please have your bed partner help you answer) Never Sometimes Often Sleep with someone else in your bed?* Never Sometimes Often Get out of bed at night?* Never Sometimes Often If you get out of bed at night, why?Walk in your sleep?*(Please have your bed partner help you answer) Never Sometimes Often Fall out of bed at night?* Never Sometimes Often Wake up at night screaming, violent, or confused?* Never Sometimes Often Feel your heart pounding during the night?* Never Sometimes Often Sweat a lot during the night?* Never Sometimes Often Have unusual movements while asleep?*(Please have your bed partner help you answer) Never Sometimes Often Wet the bed?* Never Sometimes Often Wake up choking, wheezing, or have shortness of breath?* Never Sometimes Often Have restless, disturbed sleep?* Never Sometimes Often If your sleep is restless and/or disturbed, please describe what causes the restlessness and/or disturbance:What time do you usually get up? (AM / PM)What is Earliest Time you get up? (AM / PM)What is Latest Time you get up? (AM / PM)About how many hours / minutes of actual sleep do you get each night?While you sleep, how often do you....? (CHECK ONE FOR EACH STATEMENT)Depend on an alarm to wake up?* Never Sometimes Often “Sleepin”in the morning(more than 1 hour past your usual wake-up time)* Never Sometimes Often Have a very hard time waking up?* Never Sometimes Often Feel unable to move when waking up?* Never Sometimes Often Have dream-like images when waking up even though you are not asleep?* Never Sometimes Often Wake up confused or disoriented?* Never Sometimes Often Wake up with a headache?* Never Sometimes Often Wake up nauseous (Sick to your stomach?)* Never Sometimes Often Have a bad taste in your mouth or have heartburn?* Never Sometimes Often How many naps do you take in a usual week?*How long are you usually asleep during a nap?*Are the naps refreshing?* Yes No While you sleep, how often do you....? (CHECK ONE FOR EACH STATEMENT)Feel fatigued during the day?* Never Sometimes Often Feel sleepy during the day?* Never Sometimes Often Fall asleep unintentionally?* Never Sometimes Often Feel sad or depressed?* Never Sometimes Often Have anxiety (worry about things)?* Never Sometimes Often Feel muscular tension?* Never Sometimes Often Have thoughts racing through your mind?* Never Sometimes Often Feel weakness in your muscles when laughing, surprised, angry, or excited?* Never Sometimes Often Caffeinated coffee - cups per day:*Tea - cups per day:*Soda - cups per day:*Beer - cups per day:*Wine - cups per day:*Other alcohol - cups per day:*What beverages do you usually drink within two hours of going to bed?*Do you smoke?* Never Sometimes Often What do you smoke?Check all that apply Cigarettes Cigars Pipe How long have you been smoking?*Allergies?* Yes No How many times each week do you participate in a sport or partake in some form of exercise?*What prescription medications do you take?*What over the counter medications do you take?*Please list the name of any prescription or non-prescription sleeping pill you have taken in the past:*Do any of your relatives have a sleep problem? If so, please describe:What is your personal interpretation as to why you have your particular sleep/wake problem?Please have your spouse, family member, significant other, or any other person who is aware of your sleeping problem add additional comments below:Any Comments or Questions?To submit, what is 10+75=*NameThis field is for validation purposes and should be left unchanged.
