Gender
Male
Female
Race
African-American
Hispanic
Asian or Pacific Islander
Caucasian / White
American Indian / Native American
Marital Status
Single
Married
Divorced
Separated
Widowed
Number of Marriages
0
1
2
3
4
5
Number of Children
0
1
2
3
4
5
6
7
8 or more
What is your height?
Feet
3
4
5
6
7
Inches
1
2
3
4
5
6
7
8
9
10
11
What is your current weight?
What is your previous weight? (one year ago)
What is the highest grade you finished in school?
Grades 1-8
Grades 9-11
High school graduate / GED equivalent
Junior college / vocational degree
Some college (less than 4 years)
College degree
Advanced degree (Masters, PhD, MD, JD)
Do you have military experience?
Yes
No
Combat experience?
Yes
No
Employment History
How would you describe your Employment?
Homemaker
On disability
Unemployed
Retired
Full time
Part time
Occupation:
Do you have any of the following job requirements?
Work rotating shifts
Work night shift
Travel across time zones
Driving a vehicle
Work with dangerous equipment or in hazardous situations
Work with hazardous substances
None of the above
What is your sleep problem?
Difficulty falling asleep
Difficulty staying asleep
Stop breathing while asleep
Excessive daytime sleepiness
Excessive fatigue
Snoring
Unusual behaviors during sleep or during awakenings from sleep
Sleeping more now than a year ago
Other:
Is your sleep problem
Getting better
Getting worse
Staying the same
Who INITIALLY suspected a sleep problem?
You
Your spouse / bed-partner / roommate
Your physician
What is your physicians practice specialty?
Family Practice / Internal Medicine
Ear, Nose and Throat Specialist
Cardiologist
Pulmonary Medicine (Lung Specialist)
Neurologist
Other
Do you currently have a bed partner/roommate?
Yes
No
Did your bed partner / roommate assist with this questionnaire?
Yes
No
Have you ever had a sleep study before?
Yes
No
Were you diagnosed with a sleep disorder?
Yes
No
What disorder:
Sleep apnea
Insomnia
Narcolepsy
Restless sleep
Other:
What treatments have you had:
CPAP/BiPAP
Medication
Oxygen
Dental device
Other:
Because of your sleep problems, have you:
Considered (or are on) disability?
Yes
No
Had work (or school) difficulties?
Yes
No
Had motor vehicle accidents?
Yes
No
Had driving problems?
Yes
No
Marital or social problems?
Yes
No
Drug or alcohol use?
Yes
No
Had an injury?
Yes
No
The following questions are related to your sleep during the past few months.
WEEKDAYS
When do you usually go to sleep?
1 am
2 am
3 am
4 am
5 am
6 am
7 am
8 am
9 am
10 am
11 am
Noon
1 pm
2 pm
3 pm
4 pm
5 pm
6 pm
7 pm
8 pm
9 pm
10 pm
11 pm
Midnight
When do you usually wake up?
1 am
2 am
3 am
4 am
5 am
6 am
7 am
8 am
9 am
10 am
11 am
Noon
1 pm
2 pm
3 pm
4 pm
5 pm
6 pm
7 pm
8 pm
9 pm
10 pm
11 pm
Midnight
Do you use an alarm to awaken?
Yes
No
WEEKENDS
When do you usually go to sleep?
1 am
2 am
3 am
4 am
5 am
6 am
7 am
8 am
9 am
10 am
11 am
Noon
1 pm
2 pm
3 pm
4 pm
5 pm
6 pm
7 pm
8 pm
9 pm
10 pm
11 pm
Midnight
When do you usually wake up?
1 am
2 am
3 am
4 am
5 am
6 am
7 am
8 am
9 am
10 am
11 am
Noon
1 pm
2 pm
3 pm
4 pm
5 pm
6 pm
7 pm
8 pm
9 pm
10 pm
11 pm
Midnight
Do you use an alarm to awaken?
Yes
No
How many hours do you try to sleep?
less than 3
4-6
7
8
9
10-12
greater than 12
How long do you actually sleep?
less than 3
4-6
7
8
9
10-12
greater than 12
How satisfied are you with your… (1 = Very Satisfied, 7 = Very Dissatisfied)
Current sleep quality?
1
2
3
4
5
6
7
Current daytime alertness?
1
2
3
4
5
6
7
Ability to feel rested after your night's sleep?
1
2
3
4
5
6
7
How long do you lay in bed before falling asleep?
less than 15 min
15-30 min
31-45 min
46-60 min
greater than 1 hr
How many times do you typically awaken during the night?
Once or less
2 to 3
4 to 5
6 or more
How many times do you typically awaken to use restroom?
Once or less
2 to 3
4 to 5
6 or more
What is the total time you are unable to sleep between bedtime and your final wake-up time:
less than 15 min
15-30 min
31-45 min
46-60 min
more than 1 hr
When unable to sleep, do you do any of the following:
Watch TV or listen to music or radio in bed
Eat
Read
Use computer or internet
Worry at night
Other:
Describe any problems in your sleeping environment:
Uncomfortable temperature
Noisy room
Excessive light
Bed partner interrupts sleep
Uncomfortable bed
Pet interference
Other:
Do you take naps or doze off during the day?
Yes
No
Do your legs have a “creepy, crawling” sensation while sitting or lying quietly that causes an almost
irresistible urge to move your legs?
Yes
No
What time of day?
Morning
Afternoon
Evening
All Day
Rate the severity of this feeling:
Mild
Moderate
Severe
Does this feeling in your legs interfere with your sleep?
Yes
No
Does movement of your legs give you temporary relief?
Yes
No
How often do you (or your bed partner/roommate) find that you:
Snore so loudly that it would bother others near you
Never
Rarely
Sometimes
Often
Usually
Always
Sleep apart from your bed partner or roommate because of snoring
Never
Rarely
Sometimes
Often
Usually
Always
Make unusual sounds while sleeping
Never
Rarely
Sometimes
Often
Usually
Always
Have trouble breathing at night
Never
Rarely
Sometimes
Often
Usually
Always
Awaken choking, gasping or smothering
Never
Rarely
Sometimes
Often
Usually
Always
Awaken coughing
Never
Rarely
Sometimes
Often
Usually
Always
Have others say that you stop breathing in your sleep
Never
Rarely
Sometimes
Often
Usually
Always
Are bothered by physical problems, sensations or pain at night
Never
Rarely
Sometimes
Often
Usually
Always
Awaken with dry mouth and/or sore throat
Never
Rarely
Sometimes
Often
Usually
Always
Have palpitations or chest pain at night
Never
Rarely
Sometimes
Often
Usually
Always
Awaken during the night or in the morning with a headache
Never
Rarely
Sometimes
Often
Usually
Always
Are awakened with hot flashes or sweating
Never
Rarely
Sometimes
Often
Usually
Always
Have twitches, jerks or startled movements during sleep
Never
Rarely
Sometimes
Often
Usually
Always
Have restless sleep or awaken with bedclothes or sheets in a mess
Never
Rarely
Sometimes
Often
Usually
Always
Sit up and scream while asleep or suddenly wake up scared
Never
Rarely
Sometimes
Often
Usually
Always
Talk while sleeping
Never
Rarely
Sometimes
Often
Usually
Always
Walk or eat while asleep, with no recall of this the next day
Never
Rarely
Sometimes
Often
Usually
Always
Act out your dreams
Never
Rarely
Sometimes
Often
Usually
Always
Afraid to be alone at night
Never
Rarely
Sometimes
Often
Usually
Always
Grind teeth while sleeping
Never
Rarely
Sometimes
Often
Usually
Always
Wet the bed
Never
Rarely
Sometimes
Often
Usually
Always
Are tired and fatigued even when you are not sleepy
Never
Rarely
Sometimes
Often
Usually
Always
Doze or nod off while at work
Never
Rarely
Sometimes
Often
Usually
Always
Doze or nod off while driving
Never
Rarely
Sometimes
Often
Usually
Always
Feel sleepy and drowsy all day
Never
Rarely
Sometimes
Often
Usually
Always
Wake up tired or NOT rested
Never
Rarely
Sometimes
Often
Usually
Always
Feel tired or sleepy in the morning
Never
Rarely
Sometimes
Often
Usually
Always
Feel tired or sleepy during the afternoon
Never
Rarely
Sometimes
Often
Usually
Always
Feel tired or sleepy in the early evening
Never
Rarely
Sometimes
Often
Usually
Always
Are more awake and alert in the evening than morning
Never
Rarely
Sometimes
Often
Usually
Always
Wake up and are alert in the morning before it is time to get up
Never
Rarely
Sometimes
Often
Usually
Always
Sleep longer on weekends or holidays than on weekdays
Never
Rarely
Sometimes
Often
Usually
Always
Have trouble falling asleep at your usual bedtime
Never
Rarely
Sometimes
Often
Usually
Always
Have trouble staying asleep after you have fallen asleep
Never
Rarely
Sometimes
Often
Usually
Always
Awaken early in the morning and have trouble getting back to sleep
Never
Rarely
Sometimes
Often
Usually
Always
Lie awake at night with thoughts racing through your mind
Never
Rarely
Sometimes
Often
Usually
Always
Are too full of energy or have many exciting/important things to do to sleep
Never
Rarely
Sometimes
Often
Usually
Always
Have frightening dreams or nightmares
Never
Rarely
Sometimes
Often
Usually
Always
Have vivid dreams shortly after falling asleep
Never
Rarely
Sometimes
Often
Usually
Always
Heard a voice or saw things like a vision while falling asleep or awakening
Never
Rarely
Sometimes
Often
Usually
Always
Felt paralyzed, totally unable to move, but mentally alert while falling asleep or wakening
Never
Rarely
Sometimes
Often
Usually
Always
Have sudden physical weakness of arms, legs or face when laughing, crying, or during other emotional
situations without dizziness
Never
Rarely
Sometimes
Often
Usually
Always
Are refreshed and awake even after short (10-15 min) naps
Never
Rarely
Sometimes
Often
Usually
Always
Use alcohol to help you sleep
Never
Rarely
Sometimes
Often
Usually
Always
Use sleeping pills to help you sleep
Never
Rarely
Sometimes
Often
Usually
Always
Use medicine to help you stay awake
Never
Rarely
Sometimes
Often
Usually
Always
Use coffee, tea, cola or other stimulants to help you stay awake
Never
Rarely
Sometimes
Often
Usually
Always