How concerned are you with how your sleep affects your physical health?*
How concerned are you with how your sleep affects your mental health?*
How concerned are you with how your sleep affects your job performance?*
How concerned are you with how your sleep affects your family life?*
How frequently do you get enough sleep to feel fully rested and at your best the following day?*
During the week, approximately how many hours of sleep would you get each day?*
How would you rate the quality of sleep that you are getting?*
Have you been told you snore?*
Have you been told you hold your breath at night while sleeping?*
Do you wake gasping for breath?*
Do you wake with a dry mouth or have frequent sore throats?*
Do you get heart burn or acid reflux?*
Do you have high blood pressure?*
Do you wake in the morning with headaches?*
Do you wake up during the night and have trouble going back to sleep?*
Do you have episodes of feeling paralysed during your sleep?*
When you are angry or surprised do your sometimes feel as though your muscles go limp?*
Have you been told you kick or jerk during your sleep or you need to move your legs to get
them comfortable?*
Do you experience an aching or crawling sensation in your legs when trying to sleep?*
Do you have vivid dreams soon after falling asleep or during naps?*
Have you ever been told or been aware that you sleep walk?*
Do you grind your teeth at night or wake with an aching jaw?*
Do you have a family history with sleep disorders?*
How long does it normally take you to fall asleep after lights out?*
On average, how many times do you wake up at night?*
Do you know what it is that is waking you?*
Do you wake naturally or with an alarm?*
Epworth Sleepiness Scale (ESS)
This scale indicates how you feel during current daily life situations.
What is the chance of you dozing off in the situations below:
While sitting and reading?*
While sitting inactive in a public place?*
As a passenger in a car for an hour without a break?*
While sitting and talking to someone?*
While sitting quietly after lunch (without alcohol)?*
While driving a vehicle and you have to stop for a few
minutes in traffic?*
