Refer A Patient
Sleep Disorder Quiz Copy
Step 1 of 2
Height & Weight Version
Symptoms & Medical History
Please check all symptoms that apply:
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
Please tell us a little about your medical history:
High blood pressure or taking medications for high blood pressure
Past heart attack
Your Sleep Schedule
How long does it usually take you to fall asleep?
Less than 30 min
More than 60 min
How often do you wake up during the night?
More than twice
Do you have problems falling back asleep after waking up?
How many hours of sleep do you usually get per night?
Do you take anything to help you sleep?
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
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
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.
Nearest Sleep Centre