80% of insomnia complaints can be traced to physiological problems or to poor sleep habits.

The purpose of this questionnaire is to help assess your complaints of insomnia, to rule out other possible causes of your symptoms, and to assess the need for a sleep study.

Do you have restless legs and/or leg cramps during the night? Yes No Do you snore? Yes No Do you have periods where you quit breathing? Yes No Do you go to bed and wake up at the same time every day? Yes No Do you get at least 8.5 hours in bed nightly? Yes No Do you remain in bed and asleep all night? Yes No Are you excessively or inappropriately tired during the day? Yes No Do you nap during the day? Yes No

Generally, if you are not tired during the day, you don’t have insomnia. The following scale will help you assess your answers:

 

If you answered yes to 5 or more questions, there is a high probability that you may have insomnia or another sleep disorder. See your Primary Care Physician (PCP) for a referral to a sleep laboratory.

 

If you answered yes to 3-5 questions, you may have insomnia or another sleep disturbance. See your PCP and discuss your symptoms.

 

If you answered yes to 3 or fewer questions, there is a low likelihood of insomnia or other sleep problems. See your PCP to review your sleep habits and complaints.