Please place a checkmark by the statements that apply to you:

(NOTE: This questionnaire is not a substitute for formal diagnosis by a medical professional)

I often have difficulty falling asleep.

I usually wake up tired, no matter how much sleep I get.

I wake up frequently in the middle of the night but can fall back asleep easily.

I wake up frequently in the middle of the night and have difficulty falling back asleep.

I wake up too early in the morning and can't get back to sleep.

If I drink alcohol, I wake up in the middle of the night and can't get back to sleep.

I have tried melatonin, but it did not help my sleep.

I often drink caffeine after lunchtime.

I am usually on my phone until I try to go to sleep.

I am told that I snore.

I often wake up with a dry or sore throat.

I don't breathe through my nose easily.

I am told that I hold my breath or gasp at night.

I have been diagnosed with sleep apnea.

I was prescribed a CPAP machine to sleep with, but I don't like using it.

I feel more fatigued or exhausted than expected or normal.

I often have heartburn at night.

I sleep with animals on my bed.

I am frequently disturbed by my child or partner.

I have restless leg syndrome (kicking or jerking legs).

I often have vivid dreams.

I never remember my dreams.

I often have disturbing nightmares.

I often wake up wet from sweating in the middle of the night..

I use marijuana or alcohol to help myself get to sleep.

I often need to fall asleep on the couch or in a chair before moving to bed.

I regularly take medications to sleep (Xanax, Ambien, Lunesta, antihistamines, Sonata, Trazodone, etc.)

I have called in sick to work due to a bad night of sleep.

I have excessive daytime sleepiness.

I am concerned that I may fall asleep while driving or when its not appropriate (in class or during meetings).

I have other trouble with sleep that was not listed above.