This questionnaire is designed to help you identify any problems you may have resulting from poor sleep patterns.
1. I have difficulty falling asleep.
2. I worry about things and have trouble relaxing.
3. I lie awake for half an hour or more before I fall asleep.
4. I feel sad and depressed.
5. I've been told that I stop breathing while I sleep, but I don't remember this when I wake up.
6. I have noticed my heart pounding or beating irregularly during the night.
7. I get morning headaches.
8. I am overweight.
9. I feel sleepy during the day even though I slept through the night.
10. During the night, I suddenly wake up gasping for breath.
11. I wake up with heartburn.
12. I have to use antacids (Rolaids, Tums, etc.) almost every week for stomach trouble.
13. When I am angry or surprised, I feel as if I'm going limp.
14. I have fallen asleep while driving.
15. I have experienced vivid nightmares or dream-like scenes upon falling asleep or waking.
16. I feel as if I am hallucinating when I fall asleep.
17. I have trouble at work because of sleepiness.
18. I feel unable to move when I am waking up or falling asleep.
19. I experience aching or "crawling" sensations in my legs.
20. Sometimes, I can't keep my legs still at night. I just have to move them.
Questions 1-4: If you mared two or more boxes, you show symptoms of insomnia, a persistent inability to fall sleep or stay awake.
Questions 5-10: If you marked three or more boxes, you show symptoms of sleep apnea, a life-threatening disorder, that causes you to stop breathing repeatedly-often several hundred times per night - during sleep.
Questions 10-12: If you marked two or more boxes, you show symptoms of gastroesophageal reflux, a disorder caused when acid from the stomach "backs up" into the esophagus during the night.
Questions 13-18: If you marked three or more boxes, you show symptoms of narcolepsy, a lifelong disorder characterized by uncontrollable sleep attacks during the day.
Questions 19-20: If you marked one or both of these boxes, you show symptoms of nocturnal myoclonus or restless legs syndrome, a disorder characterized by pain or "crawling" sensations in the legs.
This test is intended as a general source of educational information and does not contain medical advice. It should not be used for diagnosis or treatment. Only a sleep study performed at an accredited sleep center can determine if you have a specific sleep disorder.
If you'd like to schedule a sleep study or have any sleep related questions, Porter Sleep Disorders Institute is here to serve you. Call us to schedule an appointment for a sleep study today.
Porter Sleep Disorders Institute
6040 Lute Road
Portage, Indiana 46368