Sleep Score
Print out this questionnaire
and take it with you when you see your doctor. Be sure to discuss your
answers with your doctor.
Sleep Loss
___Do
you often have difficulty falling asleep?
___Do you
awaken too early in the morning?
___If you
frequently awaken during the night, do you have difficulty going back
to sleep?
___Do you
often feel tired when you awaken in the morning?
___Does sleep
loss affect your mood during the day, making you feel tense, irritable,
or depressed?
___Do you
go to sleep and wake up at different times each day?
___Is your
sleep disturbed due to frequent travel?
___Do you
have trouble sleeping because of shift work?
___Is there
light in your bedroom at night?
___Do you
sleep in a noisy environment?
___Are you
disturbed by your bed partner at night?
___Do you
exercise within 2 hours of bedtime?
___Do you
drink beverages with caffeine in the afternoon or evening?
___Do you
smoke before going to sleep or when you awaken during the night?
___Do you
have trouble falling or staying asleep because of worry?
___Have there
been recent stressful events in your life?
___During
the past month, have you had trouble sleeping because of:
___coughing,
gasping or choking
___frequent
need to urinate
___feeling
too hot
___having
pain
___Are you
taking prescribed medication to help you sleep?
___Are you
taking over-the-counter medication to help you sleep?
___Do you
regularly drink alcohol in the evening?
___Are you
keyed up and having trouble relaxing at night?
___Do you
usually sleep better away from your own bed?
Daytime Sleepiness
___Do
you often find yourself falling asleep when you don’t intend to, such
as while driving, viewing television, or watching movies?
___Does excessive
sleepiness often interfere with your work or social life?
___During
a 24-hour period, do you usually sleep more than 9 hours?
___Do you
snore heavily most nights?
___Have you
been told you have long pauses in your breathing during sleep?
___Have you
had any accidents or near-accidents because of excessive sleepiness?
___Do you
fall asleep unintentionally during the day?
___Are you
irritable during the day?
___Do you
nap intentionally?
___Do you
awaken in the morning with a headache?
___Do you
awaken in the morning with a dry mouth?
___Do you
snore loudly and have pauses in your breathing at night?
___Do your
muscles feel very weak when you are laughing, excited or angry?
___Do you
have trouble concentrating or remembering things during the day?
___Do you
awaken from sleep feeling paralyzed?
___Do you
see or hear or feel things when you are falling asleep or awakening?
___Do you
have night sweats?
___Are you
a restless sleeper?
Nighttime Disturbances
___Do your legs jerk frequently or feel uncomfortable or restless
before or during sleep?
___Have you recently walked in your sleep?
___Do you often have disturbing nightmares?
___Do you sometimes wet the bed at night?
___Have you worn down your teeth as a result of teeth grinding at night?
___Do you awaken with pain in your jaws?
___Do you know if you have seizures in your sleep?
___Do you sleepwalk frequently?
___Has it been dangerous?
___Do you thrash in your sleep?
___Do you awaken from sleep screaming, violent, or confused?
___Do you fall out of bed?
Are you taking any
medications prescribed by another doctor or any over-the-counter medicines?
If you would like
questions answered about your sleep patterns, contact:
Staci Galle, CRT, RPSGT, sdgalle@ehendrick.org,
325.670.4184.
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