Personalized Sleep Evaluation

The following questionnaire, designed by a board certified sleep specialist, will evaluate your sleep history and show how certain aspects of your lifestyle may impact your sleep. You will then receive your personalized evaluation and your Personalized Sleep Action Plansm.

This evaluation will take approximately 2 minutes to complete.


Lifestyle & Demographic
Please answer each of the following questions, then proceed to the next section.
  1. How many nights per week do you have trouble either falling asleep or staying asleep?
  Less than 3
Three or more
Why We Ask:
The frequency of difficulty falling asleep or staying asleep is important in determining whether you have a sleep disorder.
 
  1. On average, how many (8 ounce) cups of coffee, (12 ounce) glasses of caffeinated iced tea and (12 ounce) glasses of soda do you drink a day?
  Cups of Coffee
Glasses of Iced Tea
Glasses of Soda
Why We Ask:
Caffeine is a stimulant known to impact the quality of your sleep.
 
  1. Do you, regularly or on occasion, drink alcohol in the evenings, less than about 4 hours prior to bedtime?
  No
Yes
Why We Ask:
Alcohol is a depressant and is known to affect the quality of your sleep.
 
  1. What is your age?
 
Why We Ask:
Sleep patterns, and the effects of lifestyle on sleep change with age.
 
  1. What is your gender?
  Male
Female
Why We Ask:
Men and women may experience different kinds of sleep problems, like those associated with menopause, for example.
 

Symptoms Associated with Sleep Disorders
Symptoms of sleep disorders may occur when trying to sleep, during sleep and while awake at various times during the day. Note that individual symptoms may be present in one or more sleep disorders, as well as in conditions unrelated to sleep problems.
Check the box next to each symptom you experience.
Loud snoring
Breathing or snoring stops in your sleep
You awaken gasping for breath
Become sleepy during the day
Difficulty falling asleep
Difficulty remaining asleep
You awaken too early
Your mind races with many thoughts when you try to fall asleep
You often worry whether or not you will be able to fall asleep
Fatigue
You awaken with a dry mouth
Morning headaches
Irritability/ Depression
Memory impairment or Inability to concentrate
Sinus trouble, nasal congestion or post-nasal drip interfering with your sleep
Heartburn, sour belches, regurgitation, or indigestion which disrupts your sleep
Pain which delays, prevents, or awakens you from sleep
Inability to move as you are trying to go to sleep or wake up
Vivid or lifelike visions (people in room, etc) as you fall asleep or wake up
Sudden weakness or feeling your body go limp when you are angry or excited
Irresistible urge to move your legs or arms
Creeping or crawling sensation in your legs before falling asleep
Your legs or arms jerk during sleep
Frequent urination disrupting your sleep
 

Sleep Quantity and Sleep Quality
Both the quantity and the quality of sleep are vitally important to our well-being. An insufficient quantity of sleep, poor quality (i.e., interrupted) sleep or both cause sleep deficits, which may result in a multitude of symptoms including fatigue, inattention, inability to concentrate, as well as memory, mood and behavioral problems.
  1. At what time do you get in bed, turn out the lights and go to sleep? (hours:minutes)    : AM   PM
 
  1. How long does it take you to fall asleep after you have turned out the lights? (hours:minutes)    :
 
  1. How often do you awaken each night?    times per night
 
  1. What is the total time you spend awake at night after initially falling asleep? (hours:minutes)    :
 
  1. At what time do you usually wake up in the morning? (hours:minutes)    : AM   PM
 
  1. What time do you usually get out of bed? (hours:minutes)    : AM   PM
 
  1. What is the total length of your naps? (minutes)   
 

Daytime Sleepiness (Epworth Scale)
Excessive Daytime Sleepiness is an indicator of sleep disturbances.

The following Epworth Sleepiness Scale is a well-known and routinely utilized tool used by sleep professionals to assess daytime sleepiness. Read the instructions below to complete this portion of your evaluation.

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

  0123
Sitting and reading
Watching TV
Sitting, inactive, in a public place (e.g., a theater or
a meeting)
As a passenger in a car for an hour without a break
Laying down to rest in the afternoon
Sitting and talking with someone
Sitting quietly after a lunch without alcohol
In a car, while stopped for a few minutes in traffic

 
Thank you for completing this evaluation. Please enter your email and submit your replies to get your EVALUATION and PERSONALIZED SLEEP ACTION PLAN sm.


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