Sleep Questionnaire

Click here to download a PDF of our sleep questionnaire or fill out the online form below.

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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

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

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

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=*

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