Sleep Questionnaire

Do you snore loudly? (louder than talking or loud enough to be heard through closed doors?)

Has anyone observed you stop breathing during sleep?

Do you perform poorly at school or work because of sleepiness?

Have you ever fallen asleep while driving?

Are you tired during the day?

Do you feel that you do not get enough sleep at night?

Do you consume more than 3-5 caffeinated beverages during the day?

Do you “sleep in” on the weekend?

Do you find it difficult to “get up and get going” in the morning?

Do you find it difficult to “relax and wind down” in the evening?

Do you kick your legs at night?

Do you have pain in your legs during the evening hours?

Do you have any of the following:

  • Depression
  • Diabetes
  • Hypertension
  • Poor memory/concentration
  • Morning headaches
  • Heart disease
  • Gasping or choking for air at night

Thank you for taking the sleep questionnaire

If you have answered “yes” for four or more questions, you may have a problem with your sleep. Based on your answers, a sleep study may be appropriate for you. Please consult with your doctor.

For more information about the Ministry Door County Medical Center Sleep Facility, please fill out the form below and a Sleep Center representative will contact you.

First Name: *

 

Last Name: *

 

Address: *

 

City: *

 

State: *

 

Zip Code: *

 

Phone Number: *

 

Email Address: *

 

Comments or Questions:

 

* indicates a required field


 
 
Ministry's Latest Social Activities
Facebook Twitter