Sleep Questionnaire Header

Instructions:

Answer each question as accurately as you can. At the end of the questionnaire, fill in your name, email address, phone and other requested data (all optional). This information is only used to communicate results back to you. All names, phone numbers, etc. are purged after their intended use and are not made available to any other organization, commercial entity or individual.


Do you snore?



Do you feel fatigued?

If your answer is "Yes" to one or both of these questions, complete this sleep evaluation.


THE EPWORTH SLEEPINESS SCALE

How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? This refers to your usual way of life in recent times. Even if you have not done some of these things recently try to work out how they would have affected you. Use the following scale to choose the most appropriate number for each situation.

0= Would never doze
1 = Slight chance of dozing
2 = Moderate chance of dozing
3 = High chance of dozing

Sitting and reading
    0 1 2 3

Watching TV
    0 1 2 3

Sitting inactive in a public place (e.g. a theater or a meeting)
    0 1 2 3

As a passenger in a car for an hour without a break
    0 1 2 3

Lying down to rest in the afternoon when circumstances permit
    0 1 2 3

Sitting and talking to someone
    0 1 2 3

Sitting quietly after a lunch without alcohol
    0 1 2 3

In a car, while stopped for a few minutes in the traffic
    0 1 2 3


SLEEP EVALUATION

1) Do you sometimes experience a creeping feeling in your legs?
    Yes No

2) Do you or have you ever been told that you kick your legs at night?
    Yes No

3) Do you snore?
    Yes No I don't know

If "yes" please continue with #4
If "no" or "I don’t know" please continue with #8

4) Your snoring is...
    softer than talking
    as loud as talking
    louder than talking

5) Your snoring occurs...
    every/almost every night
    a few times each week
    once a week or less

6) Your snoring is also...
    frequently interrupted by pauses/choking
    occasionally interrupted by pauses/choking
    not interrupted as far as you know

7) Do you snore in every body position?
    Yes No I don't know

8) Do you have, or ever had a bed partner?
    Yes No

If "yes" please continue with #9
If "no" please continue with #12

9) Has your bed partner ever said that you have pauses in your breathing or periods of stopped breathing during your sleep?
    Yes No

10) Has your bed partner ever commented that you snore?
    Yes, loud snoring Yes, soft snoring No

11) If you snore, is it loud enough to bother her/him?
    Yes No

12) Has anyone besides a bed partner ever commented on your snoring (roommate, neighbor, family, etc.)?
    Yes, loud snoring Yes, soft snoring No

13) Do you feel fatigued or exhausted or tired or not up to par?
    nearly every day
    3 to 4 times a week
    once or twice a week
    once or twice a month
    never or hardly ever

14) Do you feel that in some way your sleep is not refreshing or restful?
    nearly every day
    3 to 4 times a week
    once or twice a week
    once or twice a month
    never or hardly ever

15) Do you have periods of the day when you have trouble paying attention, remembering things or staying awake?
    nearly every day
    3 to 4 times a week
    once or twice a week
    once or twice a month
    never or hardly ever

16) Do you have high blood pressure?
    Yes No

If "yes" are you being treated for high blood pressure?
    Yes No

17) Do you wake up during the night or in the morning with headaches?
    Yes No

18) Are you a shift worker?
    Yes No

19) Do you have trouble initiating and/or maintaining sleep?
    nearly every day
    3 to 4 times a week
    once or twice a week
    once or twice a month
    never or hardly ever

20) What do you feel is your ideal amount of sleep per day?
    2-4 5 6 7 8 9 10

21) Estimate the average number of hours of sleep you had per day during the last week.
    2-4 5 6 7 8 9 10


PERSONAL INFORMATION
 
First Name:
Last Name:
E-Mail:
Phone:
 
Height:feet   inches
Weight: pounds
Neck Size: inches
 
Male/Female?Male Female