| Yes |
No |
1. Do you have a sinus infection?
|
| Yes |
No |
2. Do you have a middle ear infection?
|
| Yes |
No |
3. Have you been told that you snore?
|
| Yes |
No |
4. Do you suffer from daytime sleepiness?
|
| Yes |
No |
5. Have you dozed off in church on occasion?
|
| Yes |
No |
6. If you doze off do you sometimes wake up with a "snort"?
|
| Yes |
No |
7. Have you been told that you hold your breath or stop breathing in your sleep?
|
| Yes |
No |
8. Do you have high blood pressure?
|
| Yes |
No |
9. Do you toss and turn a lot in your sleep?
|
| Yes |
No |
10. Do you get up to visit the bathroom more than once a night?
|
| Yes |
No |
11. Do you often feel sleepy and struggle to stay alert especially during afternoon meetings?
|
| Yes |
No |
12. Do you fall asleep while watching TV?
|
| Yes |
No |
13. Have you fallen asleep at a stop light or stop sign?
|
| Yes |
No |
14. Have you actually fallen asleep while driving?
|
| Yes |
No |
15. Do you desire more energy and less fatigue?
|
| Yes |
No |
16. Does your neck measure over 17 inches (males) or over 16 inches (females)?
|
| Yes |
No |
17. Are you more than 15 pounds overweight?
|
| Yes |
No |
18. Do you seem to be losing your sex drive or ability to perform in in bed?
|
| Yes |
No |
19. Do you get heartburn in the middle of the night?
|
| Yes |
No |
20. Do you frequently wake with a bad taste in your mouth or a dry mouth and throat?
|
| Yes |
No |
21. Do you often get morning headaches?
|
| Yes |
No |
22. Do you smoke?
|
| Yes |
No |
23. Do you suddenly wake up gasping for breath?
|
| Yes |
No |
24. Do you sometimes wake up with a pounding or irregular heartbeat?
|
| Yes |
No |
25. Do your friends and family say you're grumpy and irritable?
|
| Yes |
No |
26. Do you have short term memory problems?
|
| Yes |
No |
27. Do you not feel rested or refreshed even after 8 or 10 hours of sleep?
|
| Yes |
No |
28. Do you perspire a lot especially at night?
|
| Yes |
No |
29. Are you tired all the time?
|
| Yes |
No |
30. Do you have difficulty concentrating?
|
| Yes |
No |
31. Does anyone in your immediate family have sleep apnea?
|
| Yes |
No |
32. Do you have a diagnosis of asthma emphysema or any other chronic lung disease?
|
| Yes |
No |
33. Sometimes it is difficult to fall asleep or it takes me at least 30 minutes or more to fall asleep.
|
| Yes |
No |
34. If I wake up during the night I feel apprehensive about going back to sleep.
|
| Yes |
No |
35. I can't seem to relax because I have too many worries.
|
| Yes |
No |
36. I feel like my muscles are going limp or I am losing muscle control when I become angry or surprised.
|
| Yes |
No |
37. I have experienced vivid dream like scenes upon waking up or falling asleep.
|
| Yes |
No |
38. Sometimes I feel unable to move when waking up or falling asleep.
|
| Yes |
No |
39. Even when I try to stay awake I usually fall asleep anyway.
|
| Yes |
No |
40. I have noticed or have been told that parts of my body jerk.
|
| Yes |
No |
41. I experience aching or "crawling" sensations in my legs.
|
| Yes |
No |
42. Sometimes I cannot keep my legs from moving at night.
|
| Yes |
No |
43. I wake up with sore or achy muscles.
|
| Yes |
No |
44. I often experience muscle tension.
|
| Yes |
No |
45. I sometimes feel that I am hallucinating when I fall asleep.
|
| Yes |
No |
46. I have fallen asleep while laughing or crying. |