Sleep Assessment

Do you experience any of the following?
(circle "Yes" or "No" for each question)
 

Snore loudly

Yes    No

You or others have observed that you stop breathing or gasp for breath during sleep

Yes    No

Feel sleepy or doze off while watching TV, reading, driving or engaged in daily activities

Yes    No

Have difficulty sleeping 3 nights a week or more
(e.g., trouble falling asleep, wake frequently during the night, wake too early and cannot get back to sleep or wake unrefreshed)

Yes    No

Feel unpleasant, tingling, creeping feelings or nervousness in your legs when trying to sleep

Yes    No

Interruptions to your sleep
(e.g., nighttime heartburn, bad dreams, pain, discomfort, noise, sleep difficulties of family members, light or temperature)

Yes    No

Copyright 2004.  Robert S. Stall, MD / Stall Geriatrics.  All Rights Reserved.