Sleep Self Assessment

This sleep quiz is an important tool designed to both quickly and easily determine if a sleep disorder may possibly be present or be a factor in your overall health and well-being.

The taking of this test and the results obtained are in no way substitutes for a medical assessment or diagnostic procedure. Please begin by checking the box to any of the statements that apply to you in the form of your choice below.

Please fill out and submit the short online form with the best way to reach you, and one of our Comprehensive Sleep Care Center professionals will be happy to contact you to see if we may be of assistance in scheduling a consultation.

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General Email: [email protected]

Medication Questions: [email protected]

Durable Medical Equipment Questions: [email protected]

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Phone: 703.729.3420

Fax: 703.729.3422

E-mail: [email protected]

Click on the tabs to choose your quiz!

Insomnia Quiz

Do you have Insomnia?

Check all that apply:
- I often take 30 minutes or more to fall asleep.
- I waken during the night and have problems falling back asleep.
- I wake up earlier than I would like.
- Thoughts often race through my mind, preventing me from falling asleep.
- I often feel sad or depressed.
- I anticipate a problem with sleep several times a week.
- I worry about things and have trouble relaxing.
- I have problems falling asleep during the week, but sleep well during weekends or on vacation.
If you answered yes to two (2) or more questions in this section, you may have Insomnia which is a chronic problem in nearly 15% of the entire population.

Next Steps...
We would be happy to schedule a sleep consultation with you, please complete the form below, and we will contact you to schedule an appointment or answer any questions you may have.
First Name*
Last Name*
Phone Number*
E-mail*
Questions?
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Narcolepsy Quiz

Do you have Narcolepsy?

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- I see vivid dreamlike images when waking up or falling asleep.
- I have suddenly become weak when angered, surprised, scared or saddened.
- I have awakened to find that for several seconds I could not move.
- I have fallen asleep in social settings such as at a party or during conversations.
- I have 'sleep attacks' during the day, no matter how hard I try to stay awake.
- I have episodes of feeling paralyzed sometimes when I'm sleeping.
If you answered yes to two (2) or more questions in this section, you may have Narcolepsy, an often inherited disorder of uncontrollable sleep attacks.
Next Step…

We would be happy to schedule a sleep consultation with you, please complete the form below, and we will contact you to schedule an appointment or answer any questions you may have.
First Name*
Last Name*
Phone Number*
E-mail*
Questions?
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Periodic Leg Movement Quiz

Do you have Periodic Leg Movements?

Check all that apply:
- I've been told that my arms jerk, or my legs kick during sleep.
- I often get 'creepy crawly' feelings in my legs when lying in bed.
- I am often awakened by leg cramps or discomfort and have to walk around.
- Sometimes I can't keep my legs still at night, I just have to move them to feel comfortable.
If you answered yes to two (2) or more questions in this section, you may have Periodic Leg Movements in sleep. This disorder affects nearly 15% of those over age 55.
Next step…
We would be happy to schedule a sleep consultation with you, please complete the form below, and we will contact you to schedule an appointment or answer any questions you may have.
First Name*
Last Name*
Phone Number*
E-mail*
Questions?
CAPTCHA

Parasomnia Quiz

Do you have Parasomnia?

Check all that apply:
- I have frequent bad dreams or nightmares.
- I have been told I frequently talk, walk, or grind my teeth during sleep.
If you answered yes to both questions in this section, you may have a Parasonmia, or unusual behavior in sleep. If you have run the risk of being injured during a sleep-related event such as sleep walking, it should be evaluated.

Next Step…
We would be happy to schedule a sleep consultation with you, please complete the form below, and we will contact you to schedule an appointment or answer any questions you may have.
First Name*
Last Name*
Phone Number*
E-mail*
Questions?
CAPTCHA

Sleep Self Assessment

REQUEST AN APPOINTMENT ONLINE!

"" indicates required fields

First Name:

Last Name:*

Phone:*
Your e-mail address:*

Subject*

Message*
Patient*

New Patient

Current Patient
CAPTCHA

Click on the tabs to choose your quiz!

Do you have a sleep disorder?

Do you have Insomnia?

Do you have Narcolepsy?

Do you have Periodic Leg Movements?

Do you have Parasomnia?

COMPREHENSIVE SLEEP CARE CENTER

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