Adult Sleep Disturbance Screening


The following sleep test is for educational purposes only.  Your answers to the following questions will be compared to those given by subjects with and without sleep disturbances.

Directions: The following questions relate to the usual sleep habits during the past month only. Your answers should indicate the most accurate reply for the majority of days and nights in the past month.

Sleep Disturbance Survey

Progress:

1. During the past month, what time have you usually gone to bed at night?

2. During the past month, how long has it taken you to fall asleep at night?

3. During the past month, what time have you gotten up in the morning?

4. During the past month, how many hours of actual sleep did you get at night? (This may be different than the number of hours spent in bed.)

5a. During the past month, how often have you had trouble sleeping because you...

Cannot get to sleep in 30 minutes

5b. During the past month, how often have you had trouble sleeping because you...

Wake up in the middle of the night or early morning

5c. During the past month, how often have you had trouble sleeping because you...

Have to get up to use the bathroom

5d. During the past month, how often have you had trouble sleeping because you...

Cannot breath comfortably

5e. During the past month, how often have you had trouble sleeping because you...

Cough or snore loudly

5f. During the past month, how often have you had trouble sleeping because you...

Feel too cold

5g. During the past month, how often have you had trouble sleeping because you...

Feel too hot

5h. During the past month, how often have you had trouble sleeping because you...

Had bad dreams

5i. During the past month, how often have you had trouble sleeping because you...

Have pain

5j. During the past month, how often have you had trouble sleeping due to a reason not previously addressed

 

6. During the past month, how would you rate your sleep overall?

7. During the past month, how often have you taken medicine to help you sleep? (prescribed or over-the-counter)

8. During the past month, how often have you had trouble staying awake while driving, eating meals, or engaging in social activity?

9. During the past month, how much of a problem has it been for you to keep up enough enthusiasm to get thing done?

Please complete and receive your results by email:

The above sleep test is a screening to be used for educational purposes only.  It is not intended to replace advice given by a qualified medical professional.  Sleep disturbances can be caused by serious underlying medical conditions, which should be evaluated by your physician.

The Adult Sleep Disturbance Screening is adapted from the PSQI. All rights reserved.