Section A of Form

Do you snore?

Have you been told that you hold your breath while you sleep?

Do you wake at night gasping for breath?

Do you have no energy during the daytime?

Are you tired all of the time?

Do you wish you had more energy?

Do you often wake with a headache?

Are you irritable most or all of the time?

Do you wake up at night with a dry mouth?

Do you sweat a lot at night?

Do you wake up with your heart pounding?

Do you and your partner sleep apart?

Are you at least 20 pounds overweight?

Have you had your tonsils removed?

Do you have trouble staying awake during the day?

Do you have trouble concentrating on work?

Have you dozed off while driving?

Have you fallen asleep while driving at night?

Have you tried remedies that didn't work?

Is this getting worse over time?

Section B

Do you kick in your sleep?

Do you jump in your sleep?

In the evening, do you have a crawling sensation under your skin?

In the evening, do you have trouble sitting still?

Do your legs cramp at night?

Do you wake up tired although you know you've slept enough?

Section C

Does it take you more than 30 minutes to fall asleep?

Do thoughts race through your mind and prevent you from sleeping?

Do you wake up at night and can't go back to sleep?

Do you wake up too early?

Do you have difficulty concentrating at work?

Is your sleep unsatisfactory at least 3 nights per week?

Do you feel you can't relax?

Do you worry all of the time?

Do you feel sad or depressed?

Section D

Do you have vivid dreams as you fall asleep?

Do you have vivid dreams as you wake up?

Do you fall asleep during movies or at parties?

Do you dream during naps?

Do you have "sleep attacks" during the day, no matter how hard you try to stay awake?