Narcolepsy Screening Questionnaire Form
Please answer the following questions to help screen for narcolepsy-related sleep symptoms. This form is for informational purposes only and does not collect sensitive personal or financial information.
Full Name
First Name
Last Name
Email Address
example@example.com
How often do you experience excessive daytime sleepiness?
*
Never
Rarely
Sometimes
Often
Almost always
Do you experience sudden episodes of muscle weakness (cataplexy) triggered by emotions?
*
Yes
No
Not sure
How frequently do you have sudden sleep attacks (falling asleep unexpectedly during the day)?
*
Never
Rarely
Sometimes
Often
Almost always
Have you ever experienced sleep paralysis (being unable to move when falling asleep or waking up)?
*
Yes
No
Not sure
Do you experience vivid hallucinations when falling asleep or waking up?
*
Never
Rarely
Sometimes
Often
How long have you been experiencing these sleep symptoms?
*
Please Select
Less than 1 month
1-6 months
6-12 months
1-2 years
More than 2 years
Do your symptoms impact your daily activities or quality of life?
*
Not at all
A little
Moderately
Severely
Are you currently taking any medication for sleep or alertness?
*
Yes
No
Please list any other sleep disorders or relevant medical conditions you have been diagnosed with.
Submit Screening
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