Sleep Disorder Self Test

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		Sleep Disorder Self Test

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To take this survey, click here for the printable version.

YES	NO		Sleep Disorder Self Test
		1.	I have been told that I snore.
		2.	I have been told that I hold my breath while I sleep.
		3.	I have high blood pressure.
		4.	My friends and family say that I'm often grumpy and irritable.
		5.	I wish I had more energy.
		6.	I get morning headaches.
		7.	I often wake up gasping for breath.
		8.	I am overweight.
		9.	I often feel sleepy and struggle to remain alert during the day.
		10.	I frequently wake up with a dry mouth.
		11.	I have difficulty falling asleep.
		12.	Thoughts race through my mind and prevent me from getting to sleep.
		13.	I anticipate a problem with sleep several times a week.
		14.	I often wake up and have trouble going back to sleep.
		15.	I worry about things and have trouble relaxing.
		16.	I wake up earlier in the morning than I would like to.
		17.	I lie awake for half an hour or more before I fail asleep.
		18.	I often feel sad or depressed because I can't sleep.
		19.	I have trouble concentrating at work or school.
		20.	When I am angry or surprised, I feel like my muscles are going limp.
		21.	I have fallen asleep while driving.
		22.	I often feel like I am in a daze.
		23.	I have experienced vivid dreamlike scenes upon falling asleep or awakening.
		24.	I have fallen asleep in social settings such as movies or at a party.
		25.	I have vivid dreams soon after falling asleep or during naps.
		26.	I have "sleep attacks" during the day no matter how hard I try to stay awake.
		27.	I have episodes of feeling paralyzed during my sleep.
		28.	I wake up at night with an acid/sour taste in my mouth.
		29.	I wake up at night coughing or wheezing.
		30.	I have frequent sore throats.
		31.	I have heartburn at night.
		32.	During the night I suddenly wake up feeling like I am choking.
		33.	I have noticed (or others have commented) that parts of my body jerk during sleep.
		34.	I have been told that I kick and jerk during sleep.
		35.	When trying to go to sleep, I experience an aching or crawling sensation in my legs.
		36.	I experience leg pain or leg cramps at night.
		37.	I can't keep my legs still at night, I just have to move them to feel comfortable.
		38.	Even though I slept during the night, I feel sleepy during the day.

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Virgin Islands Ear, Nose & Throat
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9149 Estate Thomas
St. Thomas, VI 00802

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