Sleep Screening Questionnaire

Northshore Sleep Medicine’s Sleep Screening Questionnaire

1. Do you have trouble falling or staying asleep?
   __Yes ___ No
2. Do you often feel tired or sleepy when you should feel alert?
   __Yes ___ No
3. 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
4. Do you often wake up with a headache, or feeling groggy, or not refreshed?
   __Yes ___ No
5. Do you snore or have you been told you snore?
   __Yes ___ No
6. Have you ever been told that you choke, gasp, or stop breathing while you’re sleeping?
   __Yes ___ No
7. Do you have problems with memory, concentration, or irritability?
   __Yes ___ No
8. 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
9. Have you ever been told you kick or move a lot during sleep?
   __Yes ___ No
10. 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.