Home > Our Services > Sleep Medicine > Assessment Quiz

Assessment Quiz

Assessment Quiz

Take this quiz to find out if you have a sleep condition that should be evaluated by a polysomnogram. Please answer honestly. Our sleep center coordinator will help you, if you call or e-mail this quiz.

Yes No
1. Are you extremely sleepy during the day?
Yes No
2. Do you fall asleep during work, dinner, or while entertaining friends?
Yes No
3. Do you snore loudly at night?
Yes No
4. Do you stop breathing for short periods at night?
Yes No
5. Do you wake up frequently at night?
Yes No
6. Are you restless at night (do you hit, kick, or slap your bed partner)?
Yes No
7. Do you walk in your sleep?
Yes No
8. Do you wet the bed?
Yes No
9. Do you have morning headaches?
Yes No
10. Are you confused when you wake up and have great difficulty "getting going"?
Yes No
11. Have family or friends complained about disturbing changes in your personality?
Yes No
12. Do you occasionally forget about tasks you've already finished?
Yes No
13. Do you sometimes see things that aren't there (hallucinations)?
Yes No
14. Do you have trouble maintaining attention and concentrating?
Yes No
15. Do you have "spells" when you unexpectedly drop things?
Yes No
16. Do you ever feel unable to move (or paralyzed) just before you fall asleep or wake up?
Yes No
17. Do you have insomnia?
Yes No
18. Do you have a problem with impotence?
Yes No
19. Have you gained more than 10 pounds in the past year?
Yes No
20. Do you wake up in the middle of the night with heartburn?

First Name*

Last Name

Telephone*

E-mail*
(*) Required Fields

If you answered "yes" to any of these, talk to your physician or call New Milford Hospital's Center for Sleep Medicine at 860-350-7343.