Sleep Disorder Screening Tool

The following questions have been designed to help identify problems with your sleep. Please answer them as best you can.
After completing the questionnaire, you will be provided information about your risk of having a sleep disorder.


First Name: Last Name:
Gender: Male: Female: Date of Birth / /
Email: Phone:
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Yes No Don't Know
1. Do you snore?
Slightly Louder Than Breathing As Loud As Talking Louder Than Talking Very Loud -
Can Be Heard in Adjacent Rooms
2. If you snore, your snoring is...
Nearly every day 3-4 times a week 1-2 times a week 1-2 times a month Never or nearly never
3. How often do you snore?
Yes No Don't Know
4. Has your snoring ever bothered other people?
Nearly every day 3-4 times a week 1-2 times a week 1-2 times a month Never or nearly never
5. Has anyone noticed that you quit breathing during your sleep?
Nearly every day 3-4 times a week 1-2 times a week 1-2 times a month Never or nearly never
6. How often do you feel tired or fatigued after your sleep?
Nearly every day 3-4 times a week 1-2 times a week 1-2 times a month Never or nearly never
7. During your waking time, do you feel tired, fatigued, or not up to par?
Yes No
8. Have you ever nodded off or fallen asleep while driving a vehicle?
Nearly every day 3-4 times a week 1-2 times a week 1-2 times a month Never or nearly never
9. If yes, how often does it occur?
Yes No Don't Know
10. Do you have high blood pressure?