|
|---|
If you experienced any of the following symptoms in the last year, check the box beside the number. Finally, check your score.
|
Attention: Please use your valid email address.
A good night's sleep is vital to everyone's health and well being. Yest one out of three Americans have a sleep disorder which makes sleeping and waking hours miserable. Many people suffer needlessly because they are unaware that they can get help for their problem. Once diagnosed, most sleep disorders can be effectively treated.
Take this simple test which is designed to alert you to any problems with your sleep. After you finish, look through the brief descriptions of the most common sleep disorders. If you have reoccuring symptoms, seek help from a qualified physician.
|
| * |
Name |
|
| * |
Contact E-mail |
|
| |
Phone |
|
| |
Fax |
|
| * |
Subject |
|
| |
I have difficulty falling asleep. |
|
| |
I wake up during the night and have trouble falling back to sleep. |
|
| |
I wake up earlier in the morning than I would like to. |
|
| |
I've been told that I snore. |
|
| |
I've been told that I stop breathing while I sleep. |
|
| |
I suddenly wake up gasping for breath during the night. |
|
| |
I feel tired or sleepy during the day even though I slept through the night. |
|
| |
When I'm angry or surprised, I feel like I'm going limp. |
|
| |
I have experienced vivid dreamlike scenes upon falling asleep or awakening. |
|
| |
No matter how hard I try stay awake, I sometimes fall asleep anyway. |
|
| |
I feel unable to move when I am waking up or falling asleep. |
|
| |
I fall asleep while driving, even after a good night's sleep. |
|
| |
I wake up with heartburn. |
|
| |
I wake up with a bitter or bile taste in my mouth. |
|
| |
I wake up at night coughing or wheezing. |
|
| |
I have been told that I kick at night. |
|
| |
I experience aching or "crawling" sensations in my leg. Sometimes I can't keep them still at night. |
|
| |
I awake with sore or stiff muscles. |
|
|
