Sleep Quality & HabitsCheckboxSleep Quality & HabitsDifficulty falling asleepWake up frequently during the nightWake up too early and cannot fall back asleepFeel unrefreshed after sleepingSleep less than 6 hours per nightIrregular sleep scheduleSection 2: Snoring & BreathingCheckboxSnore loudlyObserved to stop breathing during sleepWake up gasping or chokingMorning dry mouth or headachesExcessive daytime sleepinessSection 3: Daytime Functioning & FatigueCheckboxFeel tired or fatigued most daysStruggle to stay awake during activitiesDifficulty concentrating or rememberingReduced productivity due to poor sleepMood changes (irritable, anxious, low)Section 4: Movement & Sleep BehaviourCheckboxUncomfortable sensations in legs at nightUrge to move legs when restingSleepwalking, talking, or acting out dreamsSudden muscle weakness with emotionsVivid dreams or hallucinationsSection 5: Neurological SymptomsCheckboxSeizures or seizure-like episodesEpisodes of confusion or memory lossFrequent headaches or migrainesMuscle weakness, numbness, or tinglingDiagnosed or suspected neurological conditionSection 6: Children (If Applicable)CheckboxChild has difficulty concentrating or learningChild is hyperactive or easily distractedChild snores or has disturbed sleepChild has frequent night awakenings or nightmaresChild has developmental or behavioural concernsSection 7: General Health & LifestyleCheckboxOverweight or recent weight gainHigh blood pressure or heart conditionCaffeine or alcohol close to bedtimeMedication affecting sleepNight shift or rotating shift workNameSurnamePhoneEmail AddressConfirm Email AddressSubmit
