| 1 |
What time do you go to bed?What time do you start your day? |
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| 2 |
Do you have difficulty falling asleep in the beginning of the night?
If yes, on average, how long does it take to fall asleep? hrs min |
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| 3 |
Do you have difficulty staying asleep throughout the night?
How long does it take to fall back to sleep? hrs min |
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| 4 |
Do you experience an unsettled, restless sensation in your legs while sleeping?
If yes, how frequently? |
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| 5 |
Have you been told that you make kicking and twitching movements while sleeping? |
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| 6 |
Do you snore at night?
If yes, how would you rate the severity? |
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| 7 |
Have you been told that you have pauses in your breathing while asleep? |
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| 8 |
Does your bed partner frequently sleep in another room because of how you sleep? |
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| 9 |
Do you frequently wake up with (check all that apply)
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| 10 |
Are you sleepy during the day? |
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| 11 |
Do you take naps often?
If yes, for how long? min hrs |
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| 12 |
How many caffeinated beverages do you consume each day? |
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| 13 |
Do you occasionally awaken feeling paralyzed? |
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| 14 |
Do you experience sudden loss of strength in your legs or arms during the day? |
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| 15 |
How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired?
0 = Never Doze
1 = Slight Chance
2 = Moderate Chance
3 = High Chance
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