Self-Assessment
(1/2)
(2/2)
I have difficulty falling asleep
Never
Rarely
Occasionally
Most nights/days
Always
I wake up during the night and have trouble getting back to sleep
Never
(Rarely
Occasionally
Most nights/days
Always
I wake up earlier than I intend or would like to
Never
Rarely
Occasionally
Most nights/days
Always
I feel tired during the day because of trouble sleeping
Never
Rarely
Occasionally
Most nights/days
Always
I use medication to help me fall asleep
Never
Rarely
Occasionally
Most nights/days
Always
Continue
I experience unpleasant sensations in my legs that cause an urge to move them
Never
Rarely
Occasionally
Most nights/days
Always
My sensations occur or worsen when I am sitting or lying down
Never
Rarely
Occasionally
Most nights/days
Always
Moving my legs improves or makes the sensations go away
Never
Rarely
Occasionally
Most nights/days
Always
I snore loudly while sleeping
Never
Rarely
Occasionally
Most nights/days
Always
I experience pauses in my breathing/choking/gasping during sleep
(or my partner has told me that I do this)
Never
Rarely
Occasionally
Most nights/days
Always
I feel sleepy during the day, even after a full night’s sleep
Never
Rarely
Occasionally
Most nights/days
Always
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