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=* PhoneThis field is for validation purposes and should be left unchanged.
