1.	Do you have problems sleeping?
	Yes  No

2.	Do you snore when you are sleeping?
	Yes  No

3.	Do you have trouble staying awake during the day?
	Yes  No

4.	Do you experience unwanted behaviors while sleeping? ie: creeping crawling sensations in your legs, jerking, grinding teeth, clenched jaw, etc.
	Yes  No

5.	Does it take longer than 20 minutes to fall asleep?
	Yes  No

6.	Do you wake up more than once at night?
	Yes  No

7.	Do you use any type of medication to help you sleep?
	Yes  No

8.	Is your sleep disturbed because of your bed partner?
	Yes  No

9.	Do you fall asleep at inappropriate times? ie: while driving, eating, or during a conversation, etc.
	Yes  No

10.	Does you job involve shift work or night work?
	Yes  No

11.	Have you had accidents or near accidents while driving because you felt so tired?
	Yes  No

12.	Have you gained more than 10 pounds in the past year?
	Yes  No

13.	Do you have frightening dreams?
	Yes  No

14.	Do you sometimes awaken with a choking sensation?
	Yes  No

15.	Have you ever been told that you stop breathing while you sleep?
	Yes  No

16.	Do you sweat a lot when you sleep?
	Yes  No

17.	Do you wake up with an intense unpleasant feeling of fear, anxiety, or dread?
	Yes  No

18.	Do you often wake up with a headache?
	Yes  No

19.	Have you been told that your legs jerk or twitch while sleeping?
	Yes  No

20.	Do you use more than one pillow while sleeping?
	Yes  No

21.	Do you have difficulty waking up in the morning?
	Yes  No

22.	Do you take frequent naps throughout the day?
	Yes  No

23.	Have you had an increased amount of stress in the past year?
	Yes  No

24.	Do you sometimes feel paralyzed or unable to move when waking up or falling asleep?
	Yes  No

25.	Do you wake up with muscle tension or a tightness in your arms or chest?
	Yes  No

26.	Please select your preferred method of contact (if you do not wish to be contact select "No Contact Needed")*
	--Please Select--TelephoneEmailNo Contact Needed

27.	Your Name

28.	City

29.	Email Address

30.	Phone Number