LAST NAME: _______________________ IDN ___________

FIRST NAME _______________________ MI _____

DATE _______/ _______/ _______

SLEEP
&
WAKE PATTERN
ASSESSMENT
QUESTIONNAIRE

PACIFIC SLEEP PROGRAM

11790 SW Barnes Rd., Suite 330, Portland, Oregon 97225
Phone 503.228.4414 FAX 503.228.7293 PACIFIC SLEEP PROGRAM
www.snoreweb.com

© Pacific Sleep Program 2005 Rev. 1-06

 Sleep & Wake Pattern Survey Sleep & Wake Pattern Survey
Name (Last, First, MI) Date
AWAKE PERIOD – Do you find that you:
Never, Rare, Some, Usually, Always,
Age Sex Question None Mild Moderate Severe Intense
67. Are drowsy or sleepy during your regular awake How Often  1 2 3 4 5
Marital Status Nickname
hours? How Severe  1 2 3 4 5
Occupation 68. Are tired and fatigued even when you’re not drowsy? How Often  1 2 3 4 5
How Severe  1 2 3 4 5
69. Do you struggle to stay awake? How Often  1 2 3 4 5
DIRECTIONS:
How Hard  1 2 3 4 5
Please answer all the questions that follow. Also, ask any other people that you feel have important information
to add, so that the answers will be as complete as possible. Place a check mark in the box when present, circle 69. Fall asleep during your regular awake hours, How Often  1 2 3 4 5
the response where indicated, or write in the appropriate answer. Sometimes it’s difficult to be exact; answer despite trying not to? How Long  1 2 3 4 5
according to what is reasonably true. If you are completely uncertain or have absolutely no idea, leave the 70. Must takes naps during the your regular awake How Often  1 2 3 4 5
question blank. hours because of sleepiness or fatigue? How Long  1 2 3 4 5
Where numbers are listed, select the number which best describes the frequency OR the intensity according to 71. Have trouble driving a car because of sleepiness? How Often  1 2 3 4 5
the following scale: How Severe  1 2 3 4 5
1 = never, none, not at all, not applicable
2 = rarely (e.g., frequency of 1 to 2 times per year) OR slight intensity 72. Seem to take a lot longer to get things done, or How Often  1 2 3 4 5
3 = sometimes, occasionally (e.g., frequency up to 1 to 2 times per month) OR mild intensity make many more mistakes than usual? How Much  1 2 3 4 5
4 = usually, quite often (e.g., frequency up to 2 to 4 times per week) OR moderate intensity 73. Have gotten into trouble at school or work How Often  1 2 3 4 5
5 = always or almost always (e.g., from 5 times per week up to virtually nightly) OR severe/ intense because of sleepiness? How Severe  1 2 3 4 5
PRIOR SLEEP EVALUATION 74. Have trouble with your social life or personal How Often  1 2 3 4 5
Have you had a previous sleep test?  No  Yes Date _____________ activities because of sleepiness or fatigue? How Severe  1 2 3 4 5
Have you seen a physician before about your sleep or alertness problem?  No  Yes Date _____________ 75. Have trouble with your marriage or with your How Often  1 2 3 4 5
home life because of sleepiness or fatigue? How Severe  1 2 3 4 5
GENERAL SLEEP PATTERNS Time, or hours, or minutes
76. Have blackouts or staring spells? How Often  1 2 3 4 5
Time you usually or most commonly go to bed
How Severe  1 2 3 4 5
Time you usually or most commonly turn out the lights
77. Do things without conscious awareness, without How Often  1 2 3 4 5
Time it usually takes you to fall asleep – after lights out
remembering having done them? How Severe  1 2 3 4 5
How many hours of sleep do you estimate that you usually get?
78. Use coffee, tea, cola drinks, or other stimulants How Often  1 2 3 4 5
How many times do you usually wake up out of sleep, even just momentarily? in order to try to stay awake and alert? How Much  1 2 3 4 5
What time do you usually finally awaken from sleep?
79. Have developed problems with your memory, or How Often  1 2 3 4 5
How long does it usually take before you feel alert, after you finally wake up? your ability to concentrate? How Severe  1 2 3 4 5
80. Have been injured because of sleepiness or fatigue? How Often  1 2 3 4 5
IF YOU ARE A SHIFT WORKER, COMPLETE THE FOLLOWING:
How Severe  1 2 3 4 5
Minutes or hours Minutes or hours Number of awakenings
to fall asleep of sleep in each sleep period 81. Seem to have become much more irritable, How Often  1 2 3 4 5
DAY Shift depressed, or worrying; without a clear reason How Severe  1 2 3 4 5
why?
EVENING Shift 82. Have attacks of physical weakness (actual loss of How Often  1 2 3 4 5
NIGHT Shift muscle control) when laughing, crying, or How Severe  1 2 3 4 5
during other emotional situations?
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 Sleep & Wake Pattern Survey Sleep & Wake Pattern Survey
AWAKENING from SLEEP PERIOD – Do you find that you: SLEEP ENVIRONMENT
Never, Rare, Some, Usually, Always,
Question None Mild Moderate Severe Intense 1. In what position do you prefer to go to sleep?  Side  Back  Stomach
51. How often do you need an alarm, the help of How Often  1 2 3 4 5
someone else, or some other aide to wake you Help Intensity  1 2 3 4 5 2. Do you usually share your bedroom with someone else?  Yes  No
up from sleep?
52. Awaken from sleep still feeling very tired or How Often  1 2 3 4 5 3. Is your sleeping area reasonably cool?  Yes  No
groggy? How Severe  1 2 3 4 5
53. Feel groggy or still very sleepy for 15 minutes, How Often  1 2 3 4 5 4. Is your sleeping area reasonably quiet?  Yes  No
or more, after you start to wake up? How Long  1 2 3 4 5
5. Is your sleeping area reasonably dark?  Yes  No
54. Awaken from sleep with your bed all torn apart, How Often  1 2 3 4 5
in disarray? How Severe  1 2 3 4 5 6. Do you go to sleep with the light on?  Yes  No
55. Awaken from sleep with a headache? How Often  1 2 3 4 5
How Severe  1 2 3 4 5 7. Do you go to sleep with music, TV, etc. on?  Yes  No
56. Awaken from sleep feeling confused or How Often  1 2 3 4 5
disoriented? How Severe  1 2 3 4 5 SLEEP ONSET PERIOD – Do you find that you:
Never, Rare, Some, Usually, Always,
57. Awaken from sleep feeling dizzy or off balance? How Often  1 2 3 4 5 Question None Mild Moderate Severe Intense
How Severe  1 2 3 4 5
8. Have trouble getting to sleep? How Often  1 2 3 4 5
58. Awaken from sleep irritable, angry? How Often  1 2 3 4 5 How Severe  1 2 3 4 5
How Severe  1 2 3 4 5
9. Lie awake at night with your mind racing; or How Often  1 2 3 4 5
59. Wake up too early from sleep – unable to fall back How Often  1 2 3 4 5 feeling worried – or depressed? How Severe  1 2 3 4 5
to sleep soundly – or unable to fall asleep again How Severe  1 2 3 4 5
10. Have too many exciting ideas or just too much How Often  1 2 3 4 5
at all?
energy to sleep after you get into bed? How Severe  1 2 3 4 5
60. Awaken from sleep with your mouth or throat dry, How Often  1 2 3 4 5
or sore and irritated? How Severe  1 2 3 4 5 11. Have trouble holding your arms and legs still – How Often  1 2 3 4 5
either in bed or when relaxing before bed, How Severe  1 2 3 4 5
61. Awaken from sleep with your voice unusually How Often  1 2 3 4 5
(because you feel a physical urge to move)?
hoarse? How Severe  1 2 3 4 5
12. Feel pain or other similar discomfort that makes it How Often  1 2 3 4 5
62. Awaken from sleep feeling depressed, despondent, How Often  1 2 3 4 5 hard to fall asleep? How Severe  1 2 3 4 5
or very anxious? How Severe  1 2 3 4 5
13. Have heard voices or seen visions – not dreams – How Often  1 2 3 4 5
63. Awaken from sleep unable to move or speak – as How Often  1 2 3 4 5 as you drift into sleep? How Intense  1 2 3 4 5
if paralyzed – yet feeling wide awake and alert?
14. Use alcoholic beverages to help you sleep? How Often  1 2 3 4 5
64. Awaken from sleep feeling stiff or sore? How Often  1 2 3 4 5
How Severe  1 2 3 4 5
15. Use medicines to help you sleep – either How Often  1 2 3 4 5
65. Sleep best on weekends, days off, and/or holidays? How Often  1 2 3 4 5 prescription or ‘over-the-counter’ non-prescription?
How Much So  1 2 3 4 5
16. Sleep best on a schedule different from most How Often  1 2 3 4 5
66. Routinely sleep 2 or more extra hours on How Often  1 2 3 4 5 other people’s? To What Degree  1 2 3 4 5
weekends, days off, and/or holidays?
17. Sleep better in a part of your residence other How Often  1 2 3 4 5
than your bedroom – or away from home? Amount of Night  1 2 3 4 5

–6– –3–
 Sleep & Wake Pattern Survey Sleep & Wake Pattern Survey
SLEEP PERIOD – Do you find that you: SLEEP PERIOD (continued) – Do you find that you:
Never, Rare, Some, Usually, Always, Never, Rare, Some, Usually, Always,
Question None Mild Moderate Severe Intense Question None Mild Moderate Severe Intense
18. Are a light sleeper, that you don’t seem to sleep How Often  1 2 3 4 5 35. Make twitching, sudden jerking, or kicking How Often  1 2 3 4 5
soundly? How Severe  1 2 3 4 5 movements during your sleep, without being How Severe  1 2 3 4 5
aware of it?
19. Awaken periodically during the night, even if it’s How Often  1 2 3 4 5
36. Awaken from sleep because of pain, or other How Often  1 2 3 4 5
just briefly? How Long  1 2 3 4 5
similar physical discomfort? How Severe  1 2 3 4 5
20. Can tell what causes the awakenings? How Often  1 2 3 4 5
37. Are you troubled during your sleep by muscle How Often  1 2 3 4 5
cramps? How Severe  1 2 3 4 5
21. Have very restless sleep, or that you seem to tear How Often  1 2 3 4 5
38. Awaken from sleep feeling dizzy and/or How Often  1 2 3 4 5
up your bed during sleep? How Severe  1 2 3 4 5
off balance? How Severe  1 2 3 4 5
22. Have you been told that you snore? How Often  1 2 3 4 5
39. Awaken from sleep feeling very anxious or How Often  1 2 3 4 5
panicky? How Severe  1 2 3 4 5
23. Have been told that you snore loudly and bother How Often  1 2 3 4 5
40. Awaken from sleep feeling quite depressed, sad, How Often  1 2 3 4 5
others? How Severe  1 2 3 4 5
or unhappy? How Severe  1 2 3 4 5
24. Have been told by others that you appear to How Often  1 2 3 4 5
41. Grind your teeth during your sleep? How Often  1 2 3 4 5
stop breathing during your sleep? How Severe  1 2 3 4 5
How Severe  1 2 3 4 5
25. Have been told that you appear to be struggling to How Often  1 2 3 4 5
42. Have vivid dreams shortly after you fall asleep? How Often  1 2 3 4 5
breathe or are choking during your sleep? How Severe  1 2 3 4 5
How Intense  1 2 3 4 5
26. Are aware, yourself, of choking or gasping for How Often  1 2 3 4 5
43. Do violent, or even destructive, things during How Often  1 2 3 4 5
breath, feeling unable to breathe? How Severe  1 2 3 4 5
your sleep? How Severe  1 2 3 4 5
27. Awaken from sleep and notice a dry mouth? How Often  1 2 3 4 5
44. Have frightening dreams or nightmares? How Often  1 2 3 4 5
How Severe  1 2 3 4 5
How Severe  1 2 3 4 5
28. Have bothersome nasal congestion during your How Often  1 2 3 4 5
45. Walk or talk in your sleep, or have periods during How Often  1 2 3 4 5
sleep? How Severe  1 2 3 4 5
your sleep when you feel or appear confused? How Severe  1 2 3 4 5
29. Awaken from sleep with heart pain, ‘angina’? How Often  1 2 3 4 5
46. Have seizures, convulsions during your sleep? How Often  1 2 3 4 5
How Severe  1 2 3 4 5
How Severe  1 2 3 4 5
30. Awaken from sleep with palpitations in your chest, How Often  1 2 3 4 5
47. Move to another location in your residence in How Often  1 2 3 4 5
feeling your heart pound or beat irregularly? How Severe  1 2 3 4 5
order to be able to sleep? Amount of Night  1 2 3 4 5
31. Awaken during the night with a headache? How Often  1 2 3 4 5
48. Experience bedwetting? How Often  1 2 3 4 5
How Severe  1 2 3 4 5
How Severe  1 2 3 4 5
32. Awaken from sleep because of heartburn, How Often  1 2 3 4 5
49. Are bothered by outside light, noise, other How Often  1 2 3 4 5
‘reflux’,‘GERD’? How Severe  1 2 3 4 5
individuals, or animals during your sleep period? How Severe  1 2 3 4 5
33. Awaken during your sleep to go to the How Often  1 2 3 4 5
50. Have trouble sleeping when you travel? How Often  1 2 3 4 5
bathroom, urinate? How Urgent  1 2 3 4 5
How Severe  1 2 3 4 5
34. Have physically restless sensations during the How Often  1 2 3 4 5
night, as if you can’t hold still? How Severe  1 2 3 4 5

–4– –5–