SLEEP SELF-ASSESSMENT

Please answer the following questions to the best of your ability
arrow&v
Do you snore at night?
If yes, how would you rate the severity?
Have you been told that you have pauses in your breathing while asleep?
Do you have difficulty falling asleep at the beginning of the night?
Do you have difficulty staying asleep throughout the night?
Do you experience a restless sensation in your legs while lying in bed?
Have you been told that you make kicking and twitching movements while asleep?
Do you feel drowsy when driving?
Do you experience excessive tiredness during the day?
Do you occasionally awaken feeling paralyzed?
Do you experience sudden loss of strength in your legs or arms during the day?
If yes, are these brought on by a sudden frightening event or laughter?
Do you experience the following:

How likely are you to doze off or fall asleep during the day in the following situations?

0 = Would never doze     1 = Slight chance of dozing     2 = Moderate chance of dozing     3 = High chance of dozing

Sitting and reading
Watching T.V.
Sitting, inactive in a public place (i.e., movie theater)
Lying down to rest in the afternoon when circumstances permit.
As a passenger in a car for an hour without a break.
Sitting and talking to someone.
In a car, while stopped for a few minutes in traffic
Sitting quietly after lunch without alcohol

0 - 9 - average score, normal population

10 - 24 - sleep specialist advice recommended

Thanks for submitting!

Disclaimer: The information found on this website is intended to be general information; it's not medical advice. Specific medical advice can only be given by a licensed professional with full knowledge of all the facts and circumstances of your particular situation. The following questions will be used for general analytical use only. Your email address is sent along with your answers and your specific responses will be connected to you. Your individual responses will not be given to any third party whatsoever. You will be added to Alpha Fertility and Sleep Center mailing lists as a result of taking this survey. Proceeding to the survey implies that you understand and agree to provisions in this disclaimer.