Yes

No

Do you snore?

Has anyone ever said you stopped breathing or periodically became very quiet during sleep?

Have you ever awakened choking or gasping for air?

Do you awaken with a headache in the morning or experience a dry mouth upon awakening?

Are you sleepy during the day?

Have you ever fallen asleep while driving or at work?

Do you take daytime naps on a regular basis?

Have you ever experienced a sudden loss of muscle strength when laughing, angry, or excited?

Do you ever have vivid dreamlike images in your mind when going to sleep or upon awakening?

Do you ever experience a feeling of paralysis when going to sleep?

Do you ever experience an uncomfortable or restless sensation in your legs when you relax or are first going to sleep, that is relived by moving or getting out of bed and walking?

Have you ever been told your legs jerk, twitch or kick while you are asleep?

Do you wake up in the morning with the sheets and bed covers in disarray after going to sleep with the bed covers in order?

Do you walk in your sleep?

Do you become agitated and at times combative during sleep and have no memory of it in the morning?

Do you rock back and forth or bang your head during sleep?

Do you grind your teeth during your sleep?

Do you think you need a sleeping pill, either prescription drug or over the counter sleeping aid in order to fall asleep?

Do you consume wine or another alcoholic beverage in order to fall asleep?

Have you been taking sleeping pills or non-prescription sleeping aids on a nightly basis for more than three weeks?

Do you lay in bed for more than thirty minutes unable to go to sleep or return to sleep?

Do you dread getting into bed because you think you will "never" fall asleep?