Take Our Sleep Test

Please check each statement that applies to you:

I have been told that I snore.
I have been told that I stop breathing when I sleep.
I feel sleepy during the day, even though I slept through the night.
I have high blood pressure.
I have been told that I am a restless sleeper, that I toss and turn during the night.
I sweat excessively during the night.
I frequently awaken with headaches.
I am overweight or have gained weight.
I seem to be losing my sex drive.
I am having trouble concentrating or remembering things.
I have difficulty falling asleep.
Thoughts race through my mind and this prevents me from sleeping.
I wake up during the night and I can't go back to sleep.
I wake up earlier in the morning than I would like.
I lie awake for half an hour or more before I fall asleep.
I have trouble concentrating when I am at work.
When I am angry, surprised or laugh, I feel like I am going limp.
I have fallen asleep while driving.
I feel like I am going around in a daze.
I have experienced vivid dream-like scenes upon falling asleep or awakening.
I have fallen asleep while laughing or crying.
I have trouble at work because of sleepiness.
I have vivid nightmares soon after falling asleep.
Sometimes, no matter how hard I try to stay awake, I fall asleep anyway.
I feel like I have to cram a full day into every hour to get anything done.
Sometimes I feel unable to move when I am waking up or falling asleep.
I experience muscle tension in my legs, even when I am otherwise relaxed.
I have noticed, or others have commented, that parts of my body jerk.
I have been told that I kick at night.
I experience aching or "crawling" sensations in my leg.
I experience leg pain during the night.
Sometimes I can't keep my legs still at night - I just have to move them.
Even though I sleep through the night, I feel sleepy during the day.
I wake up with heartburn.
I have a chronic cough.
I have to use antacids almost every week for stomach trouble.
I am hoarse in the morning.
I wake up at night coughing and wheezing.
I have frequent sore throats.
During the night I suddenly wake up gasping.

How likely are you to doze off or fall asleep in the following situations in contrast to just feeling tired? Even if you have not done some of these things recently, try to think of how they would have affected you. Use the following scale to choose the most appropriate number for each situation:

0 = would never doze
1 = slight chance of dozing
2 = moderate chance of dozing
3 = high chance of dozing

Situation
Sitting and reading 0 1 2 3
Watching TV 0 1 2 3
Sitting inactive 0 1 2 3
In a public place (theater or meeting) 0 1 2 3
As a passenger in a car for an hour without a break 0 1 2 3
Lying down to rest in the afternoon when circumstances permit 0 1 2 3
Sitting and talking to someone 0 1 2 3
Sitting quietly after lunch without alcohol 0 1 2 3
In a car while stopped for a few minutes in traffic 0 1 2 3
Are you bothered by sleepiness under other circumstances? yes no
If yes, please describe:
Have you been in a car accident due to your falling asleep at the wheel? yes no
If yes, please describe:
Have you ever had a near miss due to your falling asleep at the wheel? yes no
If yes, please describe:
Have you had other types of accidents because of your sleepiness? yes no
If yes, please describe:

Contact Information

First Name:
Last Name:
E-mail address:
Best phone # to reach you:
Best time to call: Morning Mid-day Afternoon

By clicking "Submit," your test will be emailed to our office staff, who will review your answers and contact you.