Sleep Questionnaire


I have difficulty concentrating.

I have a tendency to be drowsy during the day.

I have had injuries as the result of sleepiness during work.

I regularly experience an overwhelming urge to sleep.

I have experienced hallucinations or dreamlike images or sounds when falling asleep or waking.

I experience a creepy-crawling or tingling sensation in my legs when I try to fall asleep.

I experience an inability to keep my legs still prior to falling asleep. Movement improves this.

I work rotating shifts.

I usually watch TV or read in bed prior to sleep.

I drink alcohol within one hour of bedtime.

I am told I grind my teeth in my sleep.

I typically awaken to urinate more than once at night.

I have trouble falling asleep

I awaken frequently during the night

I am unable to return to sleep easily if I awaken during the night.

I awaken early in the morning, still tired but unable to return to sleep.

I have recently experienced sleep walking/talking or acting out of dreams.

I have been told that I stop breathing while asleep.

I awaken at night chocking, smothering or gasping for air.

I have been told that I snore.

I have been awakened by my own snoring.

I kick or jerk my legs and/or arms during sleep.

I cannot sleep on my back.

I experience morning headaches.

I awaken with nasal stuffiness that was not present when I fell asleep.

I feel I am anxious.

I have racing thoughts at sleep time.