Sleep Diagnostic Questionnaire

I feel tired or sleepy during the day

Yes

No

I have morning headaches

Yes

No

I have trouble concentrating

Yes

No

My bed partner says that I snore, choke or gasp for air during sleep

Yes

No

I take sleeping medication to help me sleep

Yes

No

I wake up frequently during the night

Yes

No

I have noticed excessive weight gain or more hypertension recently

Yes

No

I have had more mood swings, anxiety or feelings of depression recently

Yes

No

I am a restless sleeper

Yes

No

I notice restlessness, or a tingling or crawling sensation in my arms or legs

Yes

No

I am unable to keep my arms or legs still prior to falling asleep or during sleep

Yes

No

I sweat a great deal during sleep

Yes

No

I experience unusual behaviors during sleep
(describe in the box below)

 

Yes

No

I have a family member who has sleep difficulties
(describe in the box below)

 

Yes

No

I have had a previous sleep disorder evaluation or a sleep study
Please note type of study

 

The evaluation or study took place in ______month _______year

Yes

No

I have had prescribed and use a CPAP machine

Yes

No


In the section below, please rate your chances of dozing or falling asleep in each of the situations listed
(1=least likely; 3=most likely)

1

2

3

Sitting and reading

1

2

3

Watching TV

1

2

3

Lying down to rest in the afternoon

1

2

3

Sitting and talking to someone

1

2

3

Sitting, inactive in a public place (eg: theater or meeting)

1

2

3

As a passenger in a car for an hour without a break

1

2

3

Sitting quietly after lunch without alcohol

1

2

3

Sitting in a car, while stopped for a few minutes in traffic


I have a primary-care physician that I see regularly

Yes

No

The last time I visited with my primary care physician was

______month _______year

   

I reside in _______________________________________city

 

 

I have had a previous sleep disorder evaluation or a sleep study
Please note type of study

 

The evaluation or study took place in ______month _______year

   
I have had prescribed and use a CPAP machine for home use Yes No