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This questionnaire is designed to help you identify
any problems you may have resulting from poor sleep patterns. Simply
check the blank beside the symptoms you have experienced in the last year.
_____1. I have difficulty falling asleep.
_____2. I worry about things and have trouble relaxing.
_____3. I lie awake for half an hour or more before I fall asleep.
_____4. I feel sad and depressed.
_____5. I've been told that I stop breathing while I sleep, although
I don't remember this when I wake up.
_____6. I have noticed my heart pounding or beating irregularly
during the night.
_____7. I get morning headaches.
_____8. I am overweight.
_____9. I feel sleepy during the day even though I sleep through the
night.
_____10. During the night, I suddenly wake up gasping for breath.
_____11. I wake up with heartburn.
_____12. I have to use antacids almost every week for stomach
trouble.
_____13. When I am angry or surprised, I feel as if I'm going limp.
_____14. I have fallen asleep while driving.
_____15. I have experienced vivid nightmares or dream-like scenes
upon falling asleep or waking.
_____16. I feel as if I'm hallucinating when I fall asleep.
_____17. I have trouble at work because of sleepiness.
_____18. I feel unable to move when I am waking up or falling
asleep.
_____19. I experience aching or "crawling" sensations in my legs.
_____20. Sometimes I can't keep my legs still at night. I just
have to move them.
QUESTIONS 1 through 4
If you marked two or more spaces, you may show symptoms of INSOMNIA, a
persistent inability to fall asleep or stay asleep.
QUESTIONS 5 through 9
If you marked three or more spaces, you may show symptoms of SLEEP APNEA,
a life-threatening disorder that causes you to stop breathing repeatedly -
often several hundred times per night - during your sleep.
QUESTIONS 10 through 12
If you marked two or more spaces, you may show symptoms of
GASTRO ESOPHAGEAL REFLUX, a disorder caused when acid from the stomach
"backs up" into the esophagus during the night.
QUESTIONS 13 through 18
If you marked three or more spaces, you may show symptoms of NARCOLEPSY, a
life-long disorder characterized by uncontrollable sleep attacks during
the day.
QUESTIONS 19 through 20
If you marked one or both of these boxes, you may show symptoms of
NOCTURNAL MYOCLONUS or RESTLESS LEGS SYNDROME, a disorder characterized by
pain or crawling sensations in the legs.
This test in intended for a general source of education
information and does not contain medical advice. It should not be
used for diagnosis or treatment. Only an interpreted sleep study can
determine if you have specific sleep disorders.
If you have questions, speak to your doctor first, and
then contact Lisa Koons at 765-475-2326 for a sleep study at Dukes
Memorial Hospital.
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