Sleep Assessment

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Are you getting enough sleep?

Do you have sleepiness during the day?

Always
Periodically
Rarely

Do you snore while sleeping?

Yes
No

Do you awaken with a headache every morning?

Yes
No

Do you routinely have a dry mouth in the morning upon awakening?
Yes
No

Have you ever awaken from sleep gasping for breath or choking?
Yes
No

Do you routinely find it difficult to stay awake while watching TV, reading a book or attending a lecture?
Yes
No

Has anyone told you that you hold your breath, snort and often move while sleeping?
Yes
No

Have you gained weight recently?
Yes
No

Do you ever experience muscle weakness when excited or emotional?
Yes
No

Do you have difficulty falling asleep?
Always
Periodically
Rarely

Do you have difficulty maintaining sleep?
Always
Periodically
Rarely

This risk assessment is not a diagnostic tool and is not intended as a substitute for medical care. It is intended only as an educational tool.

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