Online Sleep Assessment Name ONLINE SLEEP ASSESSMENT Take this test to see if you could be affected by a sleep disorder. Insomnia I have difficulty falling asleep Thoughts race through my mind and this prevents me from sleeping. I feel afraid to go to sleep. I wake up during the night and can’t go back to sleep. I worry about things and have trouble relaxing. Despite sleeping all night, I don’t feel refreshed when I awaken. I wake up earlier in the morning than I would like to. I lie awake for half an hour or more before I fall asleep. I wake in the morning with muscle or joint stiffness and aches. I feel sad and depressed Sleep Apnea I've been told that I snore. I've been told that I stop breathing while I sleep, although I don't remember this when I wake up. I have high blood pressure. My friends and family say they have noticed changes in my personality. I am gaining weight. I sweat excessively during the night. I have noticed my heart pounding or beating irregularly during the night. I get morning headaches. I have trouble sleeping when I have a cold. I suddenly wake up gasping for breath during the night. I am overweight. I seem to be losing my sex drive. I feel sleepy during the day even though I have slept through the night. Narcolepsy I have had trouble concentrating at school or at work. When I am angry or surprised, I feel like I'm going limp. I have fallen asleep while driving. I feel like I go around in a daze. I have fallen asleep during physical effort. I feel like I am hallucinating when I fall asleep. I have fallen asleep when laughing or crying. I have trouble at work because of sleepiness. I have vivid dreams soon after falling asleep. I fall asleep during the day. No matter how hard I try to stay awake, I fall asleep anyway. I feel unable to move when I am waking up or falling asleep. Gastroesophageal Reflux I wake up with heartburn. I have a chronic cough. I have to use antacids (Rolaids, Tums, Alka-Seltzer, etc.) almost every week for stomach trouble. I have morning hoarseness. I wake up at night coughing or wheezing. I have frequent sore throats. During the night, I suddenly wake up gasping for breath. Restless Leg Syndrome Other than when exercising, I still experience muscle tension in my legs. I have noticed (or others have commented) that parts of my body jerk. I have been told that I kick at night. I experience aching or "crawling" sensations in my legs. I experience leg pain during the night. Sometimes I can't keep my legs still at night. I just have to move them. I awaken with sore or achy muscles. Even though I have slept through the night, I still feel sleepy during the day. First Name * Last Name * Email Address * Number *
