Sleep Disorder Quiz

Your Information
Age*
Gender*
- Male
- Female
Height & Weight Version*
- English Version
- Metric Version
Height*
ft
Height*
in
Weight*
lb
Height*
cm
Weight*
kg
Symptoms & Medical History
Please check all symptoms that apply:*
- Snoring
- Awakening during sleep gasping/choking/racing heart
- Difficulty falling sleep
- Difficulty staying asleep
- Tired during the day
- Leg discomfort that prevents me from falling asleep
- Unusual behaviour during sleep
- Frequent, disturbing nightmares
- Other
Please tell us a little about your medical history:
- High blood pressure or taking medications for high blood pressure
- High cholesterol
- Diabetes
- Past heart attack
- Atrial Fibrillation
- Stroke
- Chronic Pain
- Lung disease
- Depression/Anxiety
- Tonsils removed
Other*
Your Sleep Schedule
How long does it usually take you to fall asleep?
- Less than 30 min
- 30-60 min
- More than 60 min
How often do you wake up during the night?
- None
- Once
- Twice
- More than twice
Do you have problems falling back asleep after waking up?
- Yes
- No
How many hours of sleep do you usually get per night?
Do you take anything to help you sleep?
- Yes
- No
Please tell us about your usual daytime function:
- Full of energy
- Tired in the morning but well during the day
- Moderate energy, enough for important activities and some other activities
- Low energy, enough for important activated but that’s all
- No energy, struggle to get through my important activities and often take long naps
Other symptoms:
- I am often worried/anxious/planning/problem solving before bed
- I often toss and turn at night
- I frequently have a headache when I wake up
- I wake up to use the washroom more than once per night
- I’ve been told I stop breathing at night
- I talk/walk/act out my dreams in my sleep
- I feel like I am able to fall asleep anywhere

Step 1 of 2

Your Information

Symptoms & Medical History

Your Sleep Schedule

Thank you for completing the Sleep Disorders quiz, please provide us with the following contact information and the clinic representative will contact you the following business day.