Do You Have a Sleep Disorder?

1. I'm told I snore. qYes   qNo
2. I'm told I have irregular breathing when I sleep. qYes   qNo
3. I'm tired or sleepy during the day although I slept the previous night. qYes   qNo
4. I have come close to falling asleep while driving. qYes   qNo
5. I'm told I am a restless sleeper. qYes   qNo
6. I have to use the restroom at night. qYes   qNo
7. I have high blood pressure. qYes   qNo
8. I often awaken with headaches and/or dry mouth. qYes   qNo
9. I am losing my sex drive. qYes   qNo
10. When I'm hungry, surprised, or when I laugh I feel a sudden loss of muscle control. qYes   qNo
11. I have experienced vivid dreamlike scenes on falling asleep or awakening. qYes   qNo
12. sometimes I feel unable to move when I'm waking up or falling asleep. qYes   qNo
13. It takes 30 minutes or more to fall asleep. qYes   qNo
14. Thoughts race through my mind when I'm trying to go to sleep. qYes   qNo
15. I wake up during the night and can't go back to sleep. qYes   qNo
16. I feel sad or depressed most of the time. qYes   qNo
17. The muscles in  my legs are tense even when I'm relaxed. qYes   qNo
18. I'm told that I kick at night. qYes   qNo
19. I have aching/crawling sensations in my legs. qYes   qNo
20. I have leg pain at night. qYes   qNo


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INTEGRIS Sleep Disorders Center of Oklahoma

OKC Area
(405) 636-7700

Toll-Free
(888) 53-SLEEP