Sleeping Patterns Questionnaire

Select your answer to the following questions: Yes or No

Do you snore when you are sleeping?

Do you have trouble staying awake during the day?

Do you experience unwanted behaviors while sleeping? (such as crawling sensations in your legs, jerking, grinding teeth, clenched jaws)

Does it take you longer than 20 minutes to fall asleep?

Do you wake up more than once a night?

Do you use any type of medication to help you sleep? (such as over the counter sleeping aids, or prescription medications).

Is your sleep disturbed because of your bed partner?

Does your job involve shift work or night work?

Do you fall asleep at inappropriate times? (such as driving, eating, during a
conversation).

Have you had accidents or near accidents while driving because you felt so sleepy?

Have you gained more than 10 pounds in the last year?

Do you have frightening dreams?

Do you sometimes awaken with a choking sensation?

Have you been told that you stop breathing while you sleep?

Do you sweat a lot when you sleep?

Do you wake up from sleep with an intense unpleasant feeling of fear, anxiety or dread?

Do you wake up with a headache often?

Have you been told your legs jerk or twitch while sleeping?

Do you use more than one pillow while sleeping?

Do you have difficulty waking up in the morning?

Do you take frequent naps throughout the day?

Have you had an increased amount of emotional stress in the last year?

Do you sometimes feel paralyzed or unable to move when waking up or falling asleep?

Do you wake up with muscle tension or tightness in your arms or chest?

If you answered YES to three or more questions, you may have a sleep problem that should be evaluated by a physician. 

To have this questionnaire evaluated, please print and complete this form. Call or visit:

The Sleep Disorders Clinic at Campbell County Memorial Hospital

P.O. Box 3011

Gillette, Wyoming 82717 

call toll free 1-800-500-8886 or 307-686-7085.