Noran Neurological Clinic

Noran Neurological Clinic Sleep Center Questionnaire.

Sleep disorders affect millions of Americans. Understanding one's sleep disorder and getting proper treatment can be a truly life changing event.

Please take a moment to answer the following sleep-related questions to find out if a sleep study may be appropriate for you.

Do you snore? Yes No
Do you stop breathing at night? Yes No
Do you fall asleep at work? Yes No
Do you fall asleep driving? Yes No
Are you tired during the day? Yes No
Do you feel that you do not get enough sleep at night? Yes No
Do you sleep with the television on? Yes No
Do you fall asleep during a conversation? Yes No
Do you consume more than 3-5 caffeinated beverages during the day? Yes No
Do you "sleep in" on the weekend? Yes No
If you do "sleep in" on the weekend, how many extra hours do you sleep? # of hours
Have you ever been fired because of your sleepiness at work? Yes No
Do you find it difficult to "get up and get going" in the morning? Yes No
Do you find it difficult to "relax and wind down" in the evening? Yes No
Are you a shift worker? Yes No
Do you walk in your sleep? Yes No
Do you talk in your sleep? Yes No
Have you ever walked in your sleep? Yes No
Have you ever talked in your sleep? Yes No
Do you kick your legs at night? Yes No
Do you have pain in your legs during the evening hours? Yes No