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| Click the radio button next
to the main reason for your referral (one choice only). *
Click the check boxes for any other ongoing sleep problems (multiple choices ok). |
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| bruxism (grinding teeth) | circadian rhythm disorder | delayed sleep phase syndrome | |
| excessive daytime sleepiness | insomnia | narcolepsy | |
| obstructive sleep apnea | periodic limb movements of sleep | REM sleep behavioral disorder | |
| restless leg syndrome | shift work sleep disorder | sleeptalking | |
| sleepwalking |
Other |
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Previous Evaluation
Have you ever been evaluated for a sleep problem? *
Yes
No
If yes: Year:
Have you ever been treated for:
Be sure to locate and bring results of prior sleep studies/workup with you.
Have you ever been treated for:
| bruxism (grinding teeth) | circadian rhythm disorder | delayed sleep phase syndrome |
| excessive daytime sleepiness | insomnia | narcolepsy |
| obstructive sleep apnea | periodic limb movements of sleep | REM sleep behavioral disorder |
| restless leg syndrome | shift work sleep disorder | sleeptalking |
| sleepwalking | snoring | |
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Other
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Be sure to locate and bring results of prior sleep studies/workup with you.
Sleep Questions
How long have you had your sleep problem? *
How much difficulty do you have falling asleep?: * 0 = no problem, 5 = great difficulty
0 1 2 3 4 5
What time do you get in bed for the night on:
Weekdays? *Weekends? *
What time do you turn out the lights with the intention of going to sleep on: *
Weekdays Weekends
What clock time are you typically asleep by on: *
Weekdays Weekends
How many hours of sleep do you get on an average night? *
How much difficulty do you have falling asleep?: * 0 = no problem, 5 = great difficulty
0 1 2 3 4 5
What time do you get in bed for the night on:
Weekdays? *
Weekends? *
What time do you turn out the lights with the intention of going to sleep on: *
Weekdays Weekends
What clock time are you typically asleep by on: *
Weekdays Weekends
How many hours of sleep do you get on an average night? *
Page 1
Online Sleep Questionnaire
Page 2 of 6| If yes, is your snoring disruptive to others |
| NO | YES | |||
| Sleep walking * | ||||
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| Talking in your sleep * | ||||
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| Sweating * | ||||
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| Heart pounding in your chest * | ||||
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| Falling out of bed * | ||||
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| Need to urinate * | ||||
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| Bed wetting * | ||||
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| Headache * | ||||
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| Nightmares * | ||||
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| Thrashing movements * | ||||
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| Muscle cramps * | ||||
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| Leg twitching/restless legs * | ||||
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Page 2 |
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Online Sleep Questionnaire
Page 3 of 6|
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| Have you ever injured or almost injured yourself or your bed partner while you were asleep? * |
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Night Awakenings: |
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| How many times do you awaken during the night? * | |
| Average length of each awakening: | |||||||||||||||||||||||||||||||
| What is the longest single awakening you experience at night? | |||||||||||||||||||||||||||||||
| What is the average total time that you are awake during the night? | |||||||||||||||||||||||||||||||
| Why do you think you awaken at night? (Check all that apply) | |||||||||||||||||||||||||||||||
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Morning: |
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| What time do you awaken in the morning? | |||||||||||||||||||||||||||||||
| On weekdays: * On weekends: * | |||||||||||||||||||||||||||||||
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Page 3
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Online Sleep Questionnaire
Page 4 of 6
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| Have you ever fallen asleep while driving? * |
| If yes, has an accident resulted? | ||
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| Do you have a problem falling asleep inadvertently in any of these situations: (Check all that apply) | ||||||||||||
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Napping During The Week |
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| How many days during the week do you nap * | |
| How many naps do you take per day? | |||||||||||||||||||||
| What time(s) do you typically nap? | |||||||||||||||||||||
| What is the average nap duration? | |||||||||||||||||||||
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| Average duration of each weekend nap? |
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Page 4
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Medical History |
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Do you have any of the following medical problems? |
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Have you been diagnosed with any of the following conditions: |
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Surgical procedures |
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Family History |
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Page 5
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