Do You Have a Problem Sleeping ?


Sleep disorders cause more than just daytime sleepiness- a lack of restorative rest can cause accidents on the job, and on the road; effect relationships, health, and your mental prowess; and generally make you feel “disconnected” to the world around you. Sleep disorders are dangerous, but can be treated.

The following questions will help determine if you are suffering from a sleep disorder:
1. Do you have a hard time falling asleep, staying asleep, or have insomnia? Yes No
2. Do you suffer excessive daytime sleepiness? Yes No
3. Has your sleep partner ever complained about you snoring? Yes No
4. Would you say sleep or a lack of it is a problem for you? Yes No
5. As bedtime approaches do you anticipate having difficulty sleeping? Yes No
6. Do you have any unusual behaviors during sleep? Yes No
7. Do you have uncomfortable sensations in your limbs? Yes No
8. Are you currently taking any sleep aids, Over-the-Counter or prescription?
Yes No
9. Do you awaken from a night’s sleep with a sore throat, or dry mouth? Yes No
10. Have you had a sleep study in the past? Yes No
If yes is the answer to #10, please provide the date . Month Year
For questions A through H, choose the most appropriate number for each situation.
How likely are you to doze or fall asleep in the following situations?

0 = would never doze
1 = slight chance of dozing
2 = moderate chance of dozing
3 = high chance of dozing
A. Watching TV 0 1 2 3
B. Sitting, talking with someone 0 1 2 3
C. As a passenger in a car for over an hour without a break 0 1 2 3
D. Sitting down reading 0 1 2 3
E. Sitting, inactive in a public place (e.g., a movie theater or park) 0 1 2 3
F. Resting in the afternoon, lying down 0 1 2 3
G. Anytime while your at work, especially after eating 0 1 2 3
H. When driving, stopping for a few minutes in traffic 0 1 2 3
(10) or more implies excessive sleepiness
Do you have, or been told you have:
11. A snoring problem? Yes
12. Have a neck size of 17 inches or greater (men), or 16 inches or greater (women) or you are overweight? Yes
13. Stopped breathing while sleeping? Yes
14. Wake up choking or gasping? Yes
15. High Blood Pressure or overweight Yes
I’d like more information on the in Home Sleep Test
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