* indicates required field First Name * Last Name * Date * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year201820192020 Hours of Sleep * - Select -123456789101112131415161718192021222324 How many hours of sleep are you now getting in a typical night? Falling Asleep * - Select -0153045607590105120135150165180195210225240255270285300315330345360375390405420435450465480 How many minutes does it take you to fall asleep once you are in bed? (60 minutes = 1 hr) Sleep Behavior * Apnea (lapses in breathing, periods of no breathing) Asthma Bed-Wetting Falling out of Bed Frequent Coughing Grinding Your Teeth Large Body Jerks Loud Snoring Restless Sleep Rolling-Rocking Movement Shouting Screaming or Swearing Sleep Paralysis (being awake in bed and not able to move or speak) Talking in Your Sleep Twitching Arms and Legs Violent Movements Walking in Your Sleep Waking up Choking or Gasping Heart Palpitations Waking up with Heartburn Waking up with Chest Pain Waking up with Air Hunger Waking up with Terror Waking up with Frequent Urge to Urinate Waking up with Feeling of Weight on Chest Waking up with Painful Penile Erections Waking up with Frightening Images Waking up with Anxiety or Tension Waking up with” Pins and Needles” or Restlessness in Legs Other Check off the following behaviors occurring during your sleep that either you or someone else has observed in the past year. Reason for Other If you chose "Other" in "Sleep Behavior" please provide a description. Drowsy or Sleepy * Yes No Do you feel very drowsy or sleepy at any point during the day? Hallucinations * Yes No Do you have strange hallucination-like dreams while napping? Sleep Attacks * Yes No Do you ever have “sleep attacks” during the day? (periods when you cannot prevent Yourself from falling asleep) Cataplectic Attacks * Yes No Do you ever have “Cataplectic Attacks” (episodes when you suddenly feel weak in the legs and collapse? Near Accident * Yes No Have you ever had a NEAR ACCIDENT or ACCIDENT due to excessive drowsiness?