At bedtime, I worry about things

My sleep is disturbed by sadness or depression

At bedtime, I feel sad and depressed

My sleep is disturbed by thoughts racing through my mind

At bedtime, thoughts race through my mind

At bedtime, I'm afraid of not being able to go to sleep

My sleep is disturbed by fears that I might not be able to get back to sleep if I should wake up

Mental stress, worry, or anxiety worsens my sleep

I have a problem with my sleep

My night sleep is restless and disturbed

I get too little sleep at night

I feel that my sleep is abnormal

I wake up during the night

How many hours of sleep do you get at night, not including time spent awake in bed?

I feel that I have insomnia

I have trouble getting to sleep at night

How long is your longest wake period at night?

I have been unable to sleep at all for several days

I take a prescription drug which the doctor gave me mainly to help me sleep (sleeping pills, anti-depressants, tranquilizers)

When falling asleep, I have "restless legs" (a feeling of crawling, aching, or inability to keep legs still)

My sleep is disturbed by muscular tension

At bedtime, I feel muscular tension

I am very sleepy in the daytime, and this seems to go in cycles at regular intervals 

I now have trouble doing my job because of sleepiness or fatigue

I have to let someone else drive the car because I am too sleepy to do it

In the past 6 months, I have fallen asleep accidentally in some of these situations: eating a meal, talking on the phone, talking to someone, riding in a bus or car, watching TV, at a theater, reading a  book, at a lecture.

I have slept for several days at a time, or at least I have been overwhelmingly sleepy for that long

How many daytime naps (asleep for 5 minutes or more) do you take on an average working day?

How many car accidents or "near misses" have you had because of excessive sleepiness?

I am sleeping more than I used to

I see vivid dream-like images (hallucinations) either just before or just after a daytime nap, yet I am sure I am awake when they happen

When falling asleep, I feel paralyzed (unable to move)

I have dream-like images (hallucinations) when I awaken in the morning even though I know I am not asleep

I get sudden muscular weakness (or even a brief period of paralysis, being unable to move) when laughing, angry, or in situations of strong emotion

I have vivid dreams during my daytime naps

I get "weak knees" when I laugh

I find myself doing things which make no sense, such as writing nonsense instead of notes, or mixing together chocolate and gravy

Sometimes I realize I have driven my car to the wrong place, and I can't remember how I did it

I got bad grades in school because I was too sleepy

I have used "street drugs" (marijuana, "uppers", "downers", narcotics, hallucinogens, cocaine)

While drinking alcohol, I have carried out actions without being aware of them, and not remembered them the next day

I have used marijuana to help me go to sleep

I smoke tobacco within two hours of bedtime

I have used tobacco to help me go to sleep

My snoring or my breathing problem is worse if I sleep on my back

I am told I stop breathing ("hold my breath") in sleep

What is your current weight?

How much weight have you gained since age 20?

How tall are you?

My snoring or my breathing problem is worse when I have an allergy or infection in the nose, throat, or chest

I awake suddenly gasping for breath, unable to breathe

At night, my sleep disturbs my bed partner's sleep

I have a problem with my nose blocking up when I am trying to sleep (allergies, infections)

My snoring or my breathing problem is worse if I fall asleep right after drinking alcohol

How old are you now?

I have high blood pressure (or once had it)

FOR WOMEN ONLY: I have gone through menopause ("change of life")