Questionnaire

Sleep Master — Fri, 19 Jun 2009 19:15:16 +0000

Sleep dysfunction, prior to be identified as sleep disorder, can manifest in several ways, ranging from insomnia to somnolence, and from disrupted sleep to sleep deprivation. Measuring sleep dysfunction is ongoing research; and there is a number of patient-reported outcome methods and procedures that measure various aspects of sleep dysfunction.

Before going to sleep practitioner you need to make certain preparation, one of them being a questionnaire you take with you. An example of this questionnaire, as well as additional links are shown on the bottom of this page:

Please complete and return to your physician

Name: _________________________

Date: _________________________

Chance of dozing

0 = never

1 = slight

2 = moderate

3 = high

Situation

Sitting and reading

Watching TV

Sitting, inactive in a public place

Passenger in a car without a break

Lying down to rest when circumstances permit

Sitting and talking to someone

Sitting quietly after lunch, without alcohol

In a car, while stopped for a few minutes in traffic

0 1 2 3

Total: _____

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

Do you often feel sleepy during the daytime?

Do you snore, or anyone told you that you snore?

Do you know that you stop breathing during sleep?

Did you feel choking or gasping sensation during sleep?

Do your legs ‘kick’ during sleep?

Yes No

Indicate you present knowledge of Sleep Disorders (beginner/average/advanced): _____

and return the copy of this questionnaire to your physician.

Master Your Sleep » Questionnaire

Questionnaire