Clayton Sleep Institute - Adult Sleeping Quiz

Adult Sleeping Quiz

Please answer the following questions to learn if you may have a sleeping disorder.

Please remember to print your quiz upon completion to review your results prior to submitting.

*required information

Name *
Address
Email Address *
Telephone
City
State
Zip

Would you like to join our mailing list? *	yes no
Would you like for one of sleep specialists to call you about your test result? *	yes no

I have been told that I snore.		yes no
I have been told that I stop breathing while I sleep.		yes no
I have high blood pressure.		yes no
I sweat excessively during the night.		yes no
I have noticed my heart pounding or beating irregularly during the night.		yes no
I get morning headaches.		yes no
I suddenly wake up gasping for breath during the night.		yes no
I am overweight.		yes no
I seem to be losing my sex drive.		yes no
I often feel sleepy and struggle to remain alert.		yes no
I frequently wake up with a dry mouth.		yes no
I have difficulty falling alseep.		yes no
Thoughts race through my mind and prevent me from falling asleep.		yes no
I anticipate a problem with sleep almost every night.		yes no
I wake up during the night and cannot go back to sleep.		yes no
I worry about things and have trouble relaxing.		yes no
I wake up earlier in the morning than I would like.		yes no
I lie awake for half an hour or more before I fall asleep.		yes no
I often feel sad and depressed.		yes no
I have trouble concentrating at work or at school.		yes no
When I am angry or surprised, I feel like my muscles are going limp.		yes no
I have fallen asleep while driving.		yes no
I have experienced vivid dreamlike scenes upon falling asleep or awakening.		yes no
I feel like I am hallucinating when I fall asleep.		yes no
Naps are refreshing to me.		yes no
I have fallen asleep in social settings such as the movies or at a party.		yes no
I have trouble at work because of sleepiness.		yes no
I have dreams soon after falling asleep or during naps.		yes no
I have "sleep attacks" during the day no matter how hard I try to stay awake.		yes no
I have had episodes of feeling paralyzed during my sleep.		yes no
I wake up at night with an acid/sour taste in my mouth.		yes no
I wake up at night coughing or wheezing.		yes no
I have frequent sore throats.		yes no
During the night I suddenly wake up feeling like I am choking.		yes no
Other than when exercising, I experience muscle tension in my legs.		yes no
I have noticed (or others have commented) that parts of my body jerk during sleep.		yes no
I have been told that I kick at night.		yes no
When trying to go to sleep, I experience an aching or crawling sensation in my legs.		yes no
I experience leg pain or cramps during the night.		yes no

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