Please print this survey and share your answers with your physician

This survey is reprinted from www.SleepEducaiton.com.

Sleep Evaluation

This is a series of True/False questions. It will help reveal any problems in your pattern of sleep. It will also look at how your sleep affects you during the day.

Read the statements below. Answer true or false for each one. If you answer true more than twice, you may want to discuss your sleep problem with your healthcare professional.

I feel sleepy during the day, even when I get a good night's sleep.
True False

I get very irritable when I can't sleep.
  True False

I often wake up at night and have trouble falling back to sleep.
True False

It usually takes me a long time to fall asleep.
True False

I often wake up very early and can't fall back to sleep.
True False

I experience an uncomfortable/restless sensation in my legs at night.
True False

My legs often move or jerk during the night.
True False

I sometimes wake up gasping for breath.
True False

My bed partner says my snoring keeps her/him from sleeping.
True False

I've fallen asleep driving.
True False