Sleeping Questionnaire
What are your main sleeping complaints?
Trouble falling asleep Trouble remaining asleep Sleepiness throughout the day Snoring Sleepwalking Other
Do you have a prior sleep disorder diagnosis? If yes please explain in detail.
Sleep Pattern
Bedtime
Wakeup Time
Hours in bed
Awakenings
Sleep Environment & Habits
Which are your typical sleeping positions?
Back Side Stomach Head elevated In a chair Other

Please choose yes or no for the following questions.

	Yes	No
Do you eat if you wake up from your sleep during the night?
Do you eat prior to sleep?
Do you smoke prior to sleep?
Do you drink alcohol prior to sleep?
Do you read in bed prior to sleep?
Do you watch TV in bed prior to sleep?
Do you work or study in bed?
Do you share your bed with someone?
Do you have pets in the room you sleep?

Please choose yes or no for the following questions.

	Yes	No
Do you kick or jerk your legs excessively during sleep?
Do you feel experience a creeping-crawling or tingling sensation in your legs when you try to fall asleep?
Do you experience the feeling of restlessness in your legs at night?
Do you experience sudden muscle weakness in response to emotions?
Did you experience an inability to move while falling asleep or when waking up?
Did you experience hallucinations or dreamlike images when falling asleep or waking up?
Do you act on your dreams while asleep?
Do you see nightmares?
Do you talk in your sleep?
Have you sleepwalked as an adult?
Do you have thoughts start racing through your mind when you try to fall asleep?

Please choose yes or no for the following questions.

	Yes	No
Are you being told that you snore?
Are you being told that you stop breathing while asleep?
Are you awakened by your snoring?
Are you awaken choking or gasping for air?
Are you awaken short of breath?
Do you have trouble breathing through your nose?
Do you have morning headaches?
Do you sweat at night?

Please choose yes or no for the following questions.

	Yes	No
Do you feel drowsy during the day?
Do you feel tired when you wake up?
Do you take daytime naps?
DO you have uncontrollable urges to fall asleep during the day?
Did you experience blackouts?
Did you fall asleep during driving?
Do you perform poorly in school/work because of sleepiness?
Do you frequently dream during daytime naps?

0 = would never doze
1 = slight chance of dozing
2 = moderate chance of dozing
3 = high chance of dozing

Please rate how likely are you to doze off in the following situations.

	Chance of dozing
Reading
Watching TV
Sitting inactive in a public place (Theatre, meeting, etc.)
A passenger in a vehicle
Driver in a vehicle while stopped (light, traffic, etc.)
Lying down to rest
After a meal

Sleeping Questionnaire