TABLE 1: SLEEP DISORDERS BRIEF SCREENING QUESTIONNAIRE
 
   

Table 1: Sleep disorders brief screening questionnaire

 
   

Consider a referral to sleep disorders clinic, pulmonary clinic, or a sleep specialist for further evaluation if patient responds positively to any of the following questions:


In the past month...

Question	                                                       No     Yes

1.  Have you had a problem with excessive sleepiness, 
including prolonged nighttime sleep (> 9 hours)? 

Is your sleep nonrestorative (wake up feeling unrefreshed)? 

Or do you sleep during the daytime almost daily?
[Hypersomnolence Disorder]


2.  Have you noticed (or has anyone witnessed) the following: 
you snore, snort, have breathing pauses while sleeping, or 
wake up gasping for air?
[Obstructive Sleep Apnea/Breathing-Related Sleep Disorder]
[If Yes, please complete the STOP-BANG]


3.  Have you ever been told, or suspected yourself, that you
seem to act out your dreams while asleep 
(e.g., punching, flailing your arms in the air, 
making running movements, etc.)?
[REM Behavior Disorder]


4.  Have you had irresistible attacks of sleep, such as suddenly 
lapsing into sleep or napping?
[Narcolepsy]


5.  Is your sleep/wake schedule “out of sync” with other people? 
Do you have an unusual sleep/wake schedule 
(e.g., go to bed very late or sleep in very late)?
[Circadian Rhythm Sleep-Wake Disorder]


6.  Have you had unpleasant feelings in your legs and an urge 
to move your legs as bedtime approaches (not pain)?
[Restless Legs Syndrome]


7.  Have you noticed (or has anyone told you about) jerking arm/
leg movements during sleep?
[Periodic Limb Movements]


8.  Have you had (or has anyone told you about) abrupt awakenings 
from sleep beginning with a loud scream? 
Does this occur regularly/often?
[Sleep Terrors]


9.  Have you had episodes of arising from bed during sleep and 
walking about?
[Sleep Walking]


Note: Items adapted from DSM-5 criteria for Sleep-Wake Disorders. [4]

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