Northshore Sleep Medicine’s Sleep Screening Questionnaire
- Do you have trouble falling or staying asleep?
__Yes ___ No - Do you often feel tired or sleepy when you should feel alert?
__Yes ___ No - Have you ever nodded off at an inappropriate time, such as while driving? (Please answer yes if you have nodded off while stopped in traffic or at a light.)
__Yes ___ No - Do you often wake up with a headache, or feeling groggy, or not refreshed?
__Yes ___ No - Do you snore or have you been told you snore?
__Yes ___ No - Have you ever been told that you choke, gasp, or stop breathing while you’re sleeping?
__Yes ___ No - Do you have problems with memory, concentration, or irritability?
__Yes ___ No - Do you ever get unusual, uncomfortable sensations in you legs, usually occurring later in the evening that are relieved by moving your legs?
__Yes ___ No - Have you ever been told you kick or move a lot during sleep?
__Yes ___ No - Do you ever act out your dreams while sleeping?
__Yes ___ No
If you have answered “yes” to any of these questions, you may have a serious sleep disorder. Please call 847-674-3600 to schedule an evaluation.