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?*
- 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?*
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

Sleep Questionnaire

When falling asleep, do you experience the following?

While you sleep, how often do you....?

While you sleep, how often do you....?

While you sleep, how often do you....?