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SleepMed Inc. - Sleep Disorders - Self-Tests - Sleep - Sleep Assessment Form




I have been told that I snore.
   Yes  No   
I have been told that I hold my breath when I sleep.
   Yes  No   
I have high blood pressure.
   Yes  No   
My friends and family say that I'm grumpy and irritable.
   Yes  No   
I wish I had more energy.
   Yes  No   
I get morning headaches.
   Yes  No   
I often wake up gasping for breath.
   Yes  No   
I am overweight.
   Yes  No   
I often feel sleepy and struggle
to remain alert during the day.
   Yes  No   
I frequently wake with a dry mouth.
   Yes  No   
I have difficulty falling asleep.
   Yes  No   
Thoughts race through my mind
and prevent me from getting to sleep.
   Yes  No   
I anticipate a problem with sleep several times a week.
   Yes  No   
I often wake up and have trouble going back to sleep.
   Yes  No   
I worry about things and have trouble relaxing.
   Yes  No   
I wake up earlier in the morning than I would like.
   Yes  No   
I lie awake for half an hour or more before I fall asleep.
   Yes  No   
I often feel sad/depressed because I can't sleep.
   Yes  No   
I have trouble concentrating at work or school.
   Yes  No   
When I am angry or surprised,
I feel like my muscles are going limp.
   Yes  No   
I have fallen asleep while driving.
   Yes  No   
I often feel like I am in a daze.
   Yes  No   
I have experienced vivid dreamlike
scenes upon falling asleep or awakening.
   Yes  No   
I have fallen asleep in social settings
such as movies or at a party.
   Yes  No   
I have vivid dreams soon after falling asleep or during naps.
   Yes  No   
I have "sleep attacks" during the
day no matter how hard I try to stay awake.
   Yes  No   
I have episodes of feeling paralyzed during my sleep.
   Yes  No   
I wake up at night with an
acid/sour taste in my mouth.
   Yes  No   
I wake up at night coughing or wheezing.
   Yes  No   
I have frequent sore throats.
   Yes  No   
I have heartburn at night.
   Yes  No   
During the night I suddenly wake up feeling like I am choking.
   Yes  No   
I have noticed (or others have commented) that parts of my body jerk during sleep.
   Yes  No   
I have been told that I kick and jerk during sleep.
   Yes  No   
When trying to go to sleep, I experience an aching or crawling sensation in my legs.
   Yes  No   
I experience leg pain or cramps at night.
   Yes  No   
Sometimes I can't keep my legs still at night; I just have to move them to feel more comfortable.
   Yes  No   
Even though I slept during the night, I feel sleepy during the day.
   Yes  No   
 
  


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