Sleep Quiz

Is there a connection between snoring and a sleep disorder? This questionnaire could help you decide if a sleep disorder study could help you. Answer each question honestly.

  1. Are you extremely sleepy during the day?
    Yes No
  2. Do you fall asleep during work, dinner, or while entertaining friends?
    Yes No
  3. Do you snore loudly at night?
    Yes No
  4. Do you stop breathing for short periods at night?
    Yes No
  5. Do you wake up frequently at night?
    Yes No
  6. Are you restless at night (do you hit, kick, or slap you bed partner)?
    Yes No
  7. Do you walk in your sleep?
    Yes No
  8. Do you wet the bed?
    Yes No
  9. Do you have morning headaches?
    Yes No
  10. Are you confused when you wake up and have great difficulty "getting going"?
    Yes No
  11. Have family or friends complained about disturbing changes in your personality?
    Yes No
  12. Do you occasionally forget about tasks you've already finished?
    Yes No
  13. Do you sometimes see things that aren't there (hallucinations)?
    Yes No
  14. Do you have trouble maintaining attention and concentrating?
    Yes No
  15. Do you have "spells" when you unexpectedly drop things?
    Yes No
  16. Do you ever feel unable to move (or paralyzed) just before you fall asleep or wake up?
    Yes No
  17. Do you have insomnia?
    Yes No
  18. Do you have a problem with impotence?
    Yes No
  19. Have you gained more than 10 pounds in the past year?
    Yes No
  20. Do you wake up in the middle of the night with heartburn?
    Yes No

If you answered "yes" to more than five questions, give us a call and let's talk more about your sleep.

 
Rockland Ear, Nose and Throat Associates

Clarksville Court

2 Strawtown Road

West Nyack, New York  10994

(845) 727-1340

(845) 727-1349 fax