* Required fields
Name *
E-mail Address *
Contact number: *
Additional information
1. I have been told that I snore.	yes no
2. I have been told that I hold my breath while I sleep.	yes no
3. I have high blood pressure.	yes no
4. My friends and family say that I'm often grumpy and irritable.	yes no
5. I wish I had more energy.	yes no
6. I sweat excessively during the night.	yes no
7. I have noticed my heart pounding or beating irregularly during the night.	yes no
8. I get morning headaches.	yes no
9. I suddenly wake-up gasping for breath.	yes no
10. I am overweight	yes no
11. I seem to be losing my sex drive.	yes no
12. I often feel sleepy and struggle to remain alert.	yes no
13. I frequently awake with a dry mouth.	yes no
14. I have difficulty falling asleep.	yes no
15. Thoughts race through my mind and prevent me from sleeping.	yes no
16. I anticipate a problem with sleep several times a week.	yes no
17. I wake up and cannot go back to sleep.	yes no
18. I worry about things and have trouble relaxing.	yes no
19. I wake up earlier in the morning than I would like to.	yes no
20. I lie awake for half an hour or more before I fall asleep.	yes no
21. I often feel sad and depressed.	yes no
22. I have trouble concentrating at work or school.	yes no
23. When I am angry or surprised, I feel like my muscles are going limp.	yes no
24. have fallen asleep while driving.	yes no
25. often feel like I am in a daze.	yes no
26. I have experienced dreamlike scenes upon falling asleep or awakening.	yes no
27. I have fallen asleep in social settings such as movies or at a party.	yes no
28. have trouble at work because of sleepiness.	yes no
29. I have dreams soon after falling asleep or during naps.	yes no
30. I have "sleep attacks" during the day no matter how hard I try to stay awake.	yes no
31. I have had episodes of feeling paralyzed during my sleep.	yes no
32. I wake up at night with an acid/sour taste in my mouth.	yes no
33. I wake up at night coughing or wheezing.	yes no
34. I have frequent sore throats.	yes no
35. During the night I suddenly wake up feeling like I'm choking	yes no
36. Other than when exercising, I experience muscle tension in my legs.	yes no
37. I have noticed ( others have commented) that parts of my body jerk during sleep.	yes no
38. I have been told that I kick at night.	yes no
39. When trying to go to sleep I experience an aching or crawling sensation in my legs.	yes no
40. I experience leg pain or cramps at night.	yes no
41. Sometimes I can't keep my legs still at night, I just have to move them to feel comfortable.	yes no
42. Even though I sleep during the night, I feel sleepy during the day.	yes no

I have read and agree to the Privacy Policy *

Spam prevention

Please enter the code shown above and click the 'Submit Form' button. This additional step is required to help protect against message spam.

Enter code above:

Web page software from RezBuilder.com