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    Is there a connection between snoring and a sleep disorder?
    This questionnaire could help decide if a polysomnogram could help you.
    Answer each question honestly.

    * - denotes a required field
     Student Information
    *** First Name Last Name
    *** Phone# * Email
    1. * Are you extremely sleepy during the day?  Yes No
    2. * Do you fall asleep during work, dinner, or while entertaining friends without alcohol?  Yes No
    3. * Do you snore loudly at night?  Yes No
    4. * Do you stop breathing for short periods at night?  Yes No
    5. * Do you wake up frequently at night?  Yes No
    6. * Are you restless at night (do you hit, kick or slap your bed partner)?  Yes No
    7. * Do you walk in your sleep?  Yes No
    8. * Do you wet the bed?  Yes No
    9. * Do you have morning headaches?  Yes No
    10. * Are you confused when you wake up and have great difficulty "getting going"?  Yes No
    11. * Have family or friends complained about disturbing changes in your personality?  Yes No
    12. * Do you occasionally forget about tasks you've already finished?  Yes No
    13. * Do you sometimes see things that aren't there (hallucinations)?  Yes No
    14. * Do you have trouble maintaining attention and concentrating?  Yes No
    15. * Do you have "spells" when you unexpextedly drop things?  Yes No
    16. * Do you ever feel unable to move (or paralyzed) just before you fall asleep or wake up?  Yes No
    17. * Do you have insomnia?  Yes No
    18. * Do you have or ever had high blood pressure?  Yes No
    19. * Have you gained more than 10 pounds in the past year?  Yes No
    20. * Do you wake up in the middle of the night with heartburn?  Yes No
    21. * Will you like to review your results with a sleep center representative?  Yes No

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