Sleep Assessment
Questionnaire used to identify sleep disorder candidates
For Patient:
First Name:      Last Name: 
Date of birth:     Height:     Weight:     Age: 
Please list any medical problems within the last 5 years (hypertension, diabetes, surgery, etc.)

Have you suffered a heart attack or stroke?     When? 

Select the appropriate response for each:

     1. Do you snore at night? 
     2. Witnessed pauses in breathing while asleep? 
     3. Do you have difficulty falling asleep? 
     4. Do you have difficulty maintaining sleep? 
     5. Experience a restless sensation in legs while lying awake in bed? 
     6. Kicking and twitching movements while asleep? 
     7. Experience excessive daytime tiredness? 
     8. Have you ever awakened feeling paralyzed? 
     9. Experienced a sudden loss of strength in your arms or legs? 
     10. If the previous answer is Yes, were these events brought on by a sudden, frightening event or laughter? 

Check all that apply:

Do you frequently awaken with: