Sleep Disorder Survey

Do you have a sleep disorder?

To find out, take this survey. Or, contact us today: (516) 374-8830, centerforsleep@snch.org.

* Denotes a required field

First Name
Last Name
Phone#
Email*
Are you extremely sleepy during the day?*
Do you fall asleep during work, dinner, or while entertaining friends without alcohol?*
Do you snore loudly at night?*
Do you stop breathing for short periods at night?*
Do you wake up frequently at night?*
Are you restless at night (do you hit, kick or slap your bed partner)?*
Do you walk in your sleep?*
Do you wet the bed?*
Do you have morning headaches?*
Are you confused when you wake up and have great difficulty "getting going"?*
Have family or friends complained about disturbing changes in your personality?*
Do you occasionally forget about tasks you've already finished?*
Do you sometimes see things that aren't there (hallucinations)?*
Do you have trouble maintaining attention and concentrating?*
Do you have "spells" when you unexpectedly drop things?*
Do you ever feel unable to move (or paralyzed) just before you fall asleep or wake up?*
Do you have insomnia?*
Do you have or have you ever had high blood pressure?*
Have you gained more than 10 pounds in the past year?*
Do you wake up in the middle of the night with heartburn?*
Would you like to review your results with a sleep center representative?*
Please enter the code you see*

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