How many hours of sleep do you typically get per night?
a) Less than 6 hours b) 6-7 hours c) 7-8 hours d) More than 8 hours
Do you have trouble falling asleep or staying asleep?
a) Yes, I have trouble falling asleep b) Yes, I have trouble staying asleep c) Yes, I have trouble with both d) No, I do not have trouble sleeping
Do you snore loudly or gasp for air during sleep?
a) Yes, I snore loudly b) Yes, I gasp for air during sleep c) Yes, I do both d) No, I do not snore or gasp for air
Do you feel refreshed and energized when you wake up in the morning?
a) Yes, I feel refreshed and energized b) No, I feel tired and groggy c) It varies from day to day d) I am not sure
Do you often feel sleepy or doze off during the day?
a) Yes, I often feel sleepy or doze off during the day b) No, I do not feel sleepy or doze off during the day c) Sometimes, depending on the day or circumstances d) I am not sure
Have you been diagnosed with a sleep disorder, such as sleep apnea, insomnia, or restless leg syndrome?
a) Yes, I have been diagnosed with a sleep disorder b) No, I have not been diagnosed with a sleep disorder c) I am not sure d) Not applicable
How long has it been since you had a comprehensive sleep evaluation?
a) Within the past year b) Within the past 2-3 years c) Within the past 5 years d) I have never had a comprehensive sleep evaluation
