Molly zzz's Sleep Disorders Survey
1.
Molly zzz's Sleep Disorders Survey
1.
When it's time to get up
I feel rested and refreshed
I'm tired
It varies
2.
I usually sleep
4 hours or less
4 to 6 hours
6 to 8 hours
8 to 10 hours
10 to 12 hours
12 hours or more
3.
My age group is
15 and under
16 to 21
22 to 35
36 to 45
46 to 55
56 to 65
66 to 75
75 and over
4.
I sometimes or often have trouble
Getting to sleep
Waking during the night
Waking too early
Waking up on time
Staying awake during the day
None of the above
I sleep very well
5.
Do you know someone who has a sleep disorder?
Yes - myself
Yes - someone else
I may have one
Possibly
No
6.
In what sleep disorders are you most interested?
Periodic limb movement disorder (PLMD/PLMS)
Restless legs syndrome (RLS)
Sleep apnea
Delayed or advanced sleep phase syndrome
Night terrors or nightmares
Insomnia
Snoring
Tooth grinding
Bedwetting
Narcolepsy
Sleep walking
Other
Other (Please Specify)
Created with eSurveysPro.com
Survey Software
.