Robert Wood Johnson University Hospital
New Brunswick • Somerset

Interactive Sleep Disorders Assessment

Do you have a sleep disorder?

Being sleepy can cause you to have a car accident or make mistakes at work. Sleep disorders can contribute to heart disease, high blood pressure, diabetes and other medical problems.

Sleep disorders are dangerous, but can be treated.

To see if you may have a sleep disorder, fill out the questions below. Enter a number for questions A through H, and check Yes or No for questions 1 through 10.

Do you have, or been told you have:

* 1. Have you ever been diagnosed with a sleep disorder?
* 2. Do you currently suffer from insomnia?
* 3. Do you suffer excessive daytime sleepiness?
* 4. Do you have any unusual behaviors during sleep?
* 5. Do you have uncomfortable sensations in your limbs?
* 6. Have you had a sleep study in the past?

How likely are you to doze or fall asleep in the following situations?

Epworth Scale enter 0 to 3 for each situation
0 = would never doze
1 = slight chance of dozing
2 = moderate chance of dozing
3 = high chance of dozing

* A. Sitting and reading
* B. Watching TV
* C. Sitting, inactive in a public place (e.g. a theater or meeting)
* D. As a passenger in a car for an hour without a break
* E. Lying down to rest in the afternoon when circumstances permit
* F. Sitting and talking to someone
* G. Sitting quietly after lunch without alcohol
* H. In a car, while stopping for a few minutes in the traffic

Total: 0 (Epworth Scale: 10 or more implies excessive sleepiness)

Do you have, or been told you have:

* 7. High Blood Pressure, Angina, Heart Attack, Irregular Heart Beat, Heart Failure, Stroke?
* 8. Have a neck size of 17 inches or greater (men), or 16 inches (women) or are you overweight?
* 9. Do you snore?
* 10. Stopped breathing while sleeping?
* 11. Wake up choking or gasping?

Additional Questions

* I'd like to make an appointment for a Sleep Study.
* I'd like to make an appointment for a consultation with a sleep specialist.
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