Sleep Disorder Questionnaire

Sleep Disorder Questionnaire

Answering “Sometimes” or “Usually” to any of these questions might indicate the potential for a sleep disorder, or a condition which could disrupt sleep. If this is the case, you might want to review this with your doctor.

A recent survey by The National Sleep Foundation revealed that up to 80% of primary care physicians do not ask questions about, or screen for sleep-related problems or disorders. Print this out and by being proactive in your own care and reviewing these results with your doctor, you might prevent significant disease in the future.

0	Never	Sometimes	Usually	Always
Do you have difficulty falling asleep, staying asleep, or feeling poorly rested in the morning?	0	0	0	0
Do you fall asleep unintentionally or have to fight to stay awake during the day?	0	0	0	0
Do sleep difficulties or daytime sleepiness interfere with your daily activities?	0	0	0	0
Do work or other activities prevent you from getting enough sleep?	0	0	0	0
Do you snore loudly?	0	0	0	0
Do you hold your breath, have breathing pauses, or stop breathing in your sleep?	0	0	0	0
Do you have restless or “crawling” feelings in your legs at night that go away if you move your legs?	0	0	0	0
Do you have repeated rhythmic leg jerks or leg twitches during your sleep?	0	0	0	0
Do you have nightmares, or do you scream, walk, punch, or kick in your sleep?	0	0	0	0
Do the following things disturb you in your sleep: pain, other physical symptoms, worries, medications, or other (specify)?	0	0	0	0
Do you feel sad or anxious?	0	0	0	0

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