Sleep Questionnaire Click here to download a PDF of our sleep questionnaire or fill out the online form below. Date Date Format: 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?*YesNoIf 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?*NeverSometimesOftenFeel sad or depressed?*NeverSometimesOftenHave anxiety (worry about things)?*NeverSometimesOftenFeel muscular tension?*NeverSometimesOftenFeel afraid of not being able to sleep?*NeverSometimesOftenFeel like you’re unable to move?*NeverSometimesOftenHave creeping, crawling, or aching feelings in your legs? (feel like you have to move them)*NeverSometimesOftenHave vivid, dream-like scenes even though you know you are not totally asleep?*NeverSometimesOftenHave any kind of pain or discomfort?*NeverSometimesOftenFeel afraid of the dark or anything else?*NeverSometimesOftenHow 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 periodSecond half of the sleep periodBoth, or no particular patternWhile you sleep, how often do you....? (CHECK ONE FOR EACH STATEMENT)Snore loudly?*(Please have your bed partner help you answer)NeverSometimesOftenHave pauses in your breathing (apnea) while asleep?*(Please have your bed partner help you answer)NeverSometimesOftenSleep with someone else in your bed?*NeverSometimesOftenGet out of bed at night?*NeverSometimesOftenIf you get out of bed at night, why?Walk in your sleep?*(Please have your bed partner help you answer)NeverSometimesOftenFall out of bed at night?*NeverSometimesOftenWake up at night screaming, violent, or confused?*NeverSometimesOftenFeel your heart pounding during the night?*NeverSometimesOftenSweat a lot during the night?*NeverSometimesOftenHave unusual movements while asleep?*(Please have your bed partner help you answer)NeverSometimesOftenWet the bed?*NeverSometimesOftenWake up choking, wheezing, or have shortness of breath?*NeverSometimesOftenHave restless, disturbed sleep?*NeverSometimesOftenIf 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?*NeverSometimesOften“Sleepin”in the morning(more than 1 hour past your usual wake-up time)*NeverSometimesOftenHave a very hard time waking up?*NeverSometimesOftenFeel unable to move when waking up?*NeverSometimesOftenHave dream-like images when waking up even though you are not asleep?*NeverSometimesOftenWake up confused or disoriented?*NeverSometimesOftenWake up with a headache?*NeverSometimesOftenWake up nauseous (Sick to your stomach?)*NeverSometimesOftenHave a bad taste in your mouth or have heartburn?*NeverSometimesOftenHow many naps do you take in a usual week?*How long are you usually asleep during a nap?*Are the naps refreshing?*YesNoWhile you sleep, how often do you....? (CHECK ONE FOR EACH STATEMENT)Feel fatigued during the day?*NeverSometimesOftenFeel sleepy during the day?*NeverSometimesOftenFall asleep unintentionally?*NeverSometimesOftenFeel sad or depressed?*NeverSometimesOftenHave anxiety (worry about things)?*NeverSometimesOftenFeel muscular tension?*NeverSometimesOftenHave thoughts racing through your mind?*NeverSometimesOftenFeel weakness in your muscles when laughing, surprised, angry, or excited?*NeverSometimesOftenCaffeinated 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?*NeverSometimesOftenWhat do you smoke?Check all that apply Cigarettes Cigars Pipe How long have you been smoking?*Allergies?*YesNoHow 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?*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?CAPTCHA