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Complete this questionnaire to find out if you have sleep deprivation or other sleeping problems.

This test may help you recognize and detect symptoms of sleep deprivation related to sleeping disorders. The test is intended as a general source of educational information and does not contain medical advice. It should not be used for diagnosis or treatment. Getting an evaluation at a fully accredited sleep disorders center is the best way to determine if you have serious sleep deprivation related to a sleep disorder.

To take this sleep test, write down the number of each statement that is true for you. If the statement does not apply or is false, simply go on to the next statement. To score the test, follow the directions at the end of the questionnaire.

  1. I have been told that I snore.
  2. I have been told that I hold my breath while I sleep.
  3. I have high blood pressure.
  4. My friends and family say that I'm often grumpy and irritable.
  5. I wish I had more energy.
  6. I get morning headaches.
  7. I often wake up gasping for breath.
  8. I am overweight.
  9. I often feel sleepy and struggle to remain alert during the day.
  10. I frequently wake with a dry mouth.

    Total your score for 1-10: __________

  11. I have difficulty falling asleep.
  12. Thoughts race through my mind and prevent me from getting to sleep.
  13. I anticipate a problem with sleep several times a week.
  14. I often wake up and have trouble going back to sleep.
  15. I worry about things and have trouble relaxing.
  16. I wake up earlier in the morning that I would like to.
  17. I lie awake for half an hour or more before I fall asleep.
  18. I often feel sad or depressed because I can't sleep.

    Total your score for 11-18: __________

  19. I have trouble concentrating at work or school.
  20. When I am angry or surprised, I feel like my muscles are going limp.
  21. I have fallen asleep while driving.
  22. I often feel like I am in a daze.
  23. I have experienced vivid dreamlike scenes upon falling asleep or awakening.
  24. I have fallen asleep in social settings such as movies or at a party.
  25. I have vivid dreams soon after falling asleep or during naps.
  26. I have "sleep attacks" during the day no matter how hard I try to stay awake.
  27. I have episodes of feeling paralyzed during my sleep.

    Total your score for 19-27: __________

  28. I wake up at night with an acid/sour taste in my mouth.
  29. I wake up at night coughing or wheezing.
  30. I have frequent sore throats.
  31. I have heartburn at night.
  32. During the night I suddenly wake up feeling like I am choking.

    Total your score for 28-32: __________

  33. I have noticed (or others have commented) that parts of my body jerk during sleep.
  34. I have been told that I kick and jerk during sleep.
  35. When trying to go to sleep, I experience an aching or crawling sensation in my legs.
  36. I experience leg pain or cramps at night.
  37. Sometimes I can't keep my legs stiff at night, I just have to move them to feel comfortable.
  38. Even though I slept during the night, I feel sleepy during the day.

    Total your score for 33-38: __________

How to score your sleep

Questions 1-10
If you answered YES to three or more questions, you have symptoms of SLEEP APNEA - a potentially serious disorder which causes you to stop breathing repeatedly, often hundreds of times in the night during your sleep.

Questions 11-18
If you answered YES to three or more questions, you have symptoms of INSOMNIA - a persistent inability to fall asleep or stay asleep.

Questions 19-27
If you answered YES to three or more questions, you have symptoms of NARCOLEPSY a lifelong disorder characterized by sleep attacks during the day.

Questions 28-32
If you answered YES to three or more questions, you have symptoms of GASTROESOPHAGEAL REFLUX- a disorder caused by acid "backing up" into the esophagus during sleep.

Questions 33-38
If you answered YES to three or more questions, you have symptoms of PERIODIC LIMB MOVEMENT DISORDER-uncontrollable leg or arm jerks during sleep or RESTLESS LEG SYNDROME-uncomfortable feelings in the legs at night.

Sleep test developed by Russell Rosenberg, MD, Northside Hospital Sleep Disorders Center and Atlanta School of Sleep Medicine and Technology, 5780 Peachtree-Dunwoody Road, Suite 150, Atlanta, Georgia 30342-1611, 404/851-8135.

If you feel based on this sleep questionnaire that you have any of the above conditions, please call the OhioHealth Sleep Center nearest you for further evaluation.