Sleep Self Assessment

Sleep Apnea Quiz

Check all that apply:
- I've been told that I frequently stop breathing when I sleep.
- I have been told that I snore, and it can be loud.
- My friends and family say that I'm often grumpy or irritable.
- I am overweight.
- I awaken with a dry mouth.
- I frequently have a morning headache.
- My neck measures more than 15 ¾” around
- I have high blood pressure and am on medication.
- Others tell me that my snoring is interrupted by pauses, gasps, and snorts.
- I sleep well at night, but feel sleepy during the day, especially when driving or at work.
- I have sleep attacks even though I fight them.
- I am male
If you answered yes to three (3) or more questions in this section, you may be at risk for Obstructive Sleep Apnea, a potentially serious disorder that can lead to increased risk of heart attack, stroke, or death if left untreated.

Next step…
Please fill out and submit the short online form with the best way to reach you, and one of our Comprehensive Sleep Care Center team members will be happy to contact you to see if we may be of assistance in scheduling a consultation, or answer any question
First Name*
Last Name*
Phone Number*
E-mail*
Questions?

Insomnia Quiz

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?

Narcolepsy Quiz

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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?

Periodic Leg Movement Quiz

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?

Parasomnia Quiz

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?