SLEEP QUESTIONNAIRE FOR ADULTS

and children aged 11+ years

Some of the questions in this questionnaire ask about things that may happen whilst you are
asleep (and of which you yourself would be unaware). Therefore, if possible, please complete this
questionnaire with the help of someone who can comment on what you do when you are asleep
(i.e. A sleeping partner/parent/friend etc.)

PART ONE
We would be grateful of the following general information:

Name...............................................................................................................................................

Date of birth....................................................................................................................................

Address...........................................................................................................................................

.........................................................................................................................................................

.........................................................................................................................................................

Home phone number / contact number...........................................................................................

Email address: .................................................................................................................................

General practitioner details: ...........................................................................................................

.........................................................................................................................................................

.........................................................................................................................................................

Height………………………………………Weight……………………………………………

Date questionnaire completed…………………………………………………………………….

Have you had any excessive weight gain / weight loss in the last six months? YES NO
Please describe.

Give name of any medical disease or illness which you have at present or have had in the last month

Details of any treatment or medication which you are currently taking (including sleeping
medication) or have had in the last month

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Have you any history of epilepsy / convulsions / fits / seizures? YES NO
Please describe.

Do you have frequent coughs, colds, or allergies? YES NO

Do you smoke cigarettes? YES NO

Please describe how many per day.

Do you take other substances (e.g. Cannabis)? YES NO

Please describe what and how often.

Do you drink caffeinated drinks (e.g. tea, coffee, cola)? YES NO

Please describe how many per day Tea………………………...

Coffee……………………..

Cola……………………….
What is your occupation?

What is your main sleep problem?

How long have you had it?

PART TWO
In this section we would like to know about your present sleeping habits. Your answers to the
questions should be based on your sleeping habits during the LAST ONE MONTH only.

Please circle either YES or NO, tick one of the boxes or, where appropriate, write your answer.

1) How many other people sleep in the same room as you? …………………………….
2) On average how long does it take you to fall asleep? …………………………….

3) When you are in bed awake, what do you think about? Trying to fall asleep ( )
Family matters ( )
Work / college / school ( )
Other (Please explain) ( )

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4) Do you do anything in bed to help you to get to sleep such as... Relaxation exercises ( )
Counting ( )
Lying still ( )
Reading ( )
Watching TV ( )
Listening to radio ( )
Using ear plugs ( )
Other (please explain) ( )

5) How often do you have trouble getting off to sleep? Never ( )

Less than once a month ( )
About once a month ( )
Two to four times a month ( )
Many times a week ( )
Daily ( )

6) What do you do if you can not sleep (e.g., get up, watch TV in bed, lie in the dark etc.)?

7) Do you get out of bed when you cannot sleep? YES NO

8) If you get out of bed what do you do once you are up?

9) Do you get annoyed / angry when you cannot sleep? YES NO

10) Before you fall asleep at night do your legs feel achy? YES NO

11) Do you have to move them about in bed? YES NO

12) Do you have to get out of bed to ease your aching legs? YES NO

13) How often do you wake in the night? Never ( )

Less than once a month ( )
About once a month ( )
Two to four times a month ( )
Many times a week ( )
Daily ( )

14) If you usually wake in the night,

how many times do you usually wake each night? ………………………………

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15) How long does it usually take to fall asleep again? Few minutes ( )
Up to half an hour ( )
Up to one hour ( )
One – two hours ( )
More than two hours ( )

16) What do you do before getting back to sleep again (e.g. go to the toilet, watch TV, read etc)?

17) Do you ever sleep in unusual positions? YES NO

If YES please describe.

18) If you sleep poorly how does it affect you the next day? Please describe.

19) Does a poor night’s sleep make you…

… Depressed? YES NO

… Anxious? YES NO

… Irritable? YES NO

… Tired? YES NO

20) Does a poor night sleep affect your…

… Concentration? YES NO

… Memory? YES NO

… Ability to work? YES NO

21) How long would you like to sleep for each night? ……………….

22) How long do you think normal people of your age sleep for each night? ……………….

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PART THREE
Some people sleep differently during the week than on weekends or holidays. Please answer the
following questions about how you have been sleeping during the weekdays and also at
weekends/holidays. Please write your answer or circle YES or NO. Base your answers on your
sleep over the LAST ONE MONTH. If there is no difference between your sleep on weekdays and
weekends/holidays then just fill in the column marked “Weekdays”.

Weekdays Weekends or Holidays

1) What time do you start getting ready for

bed?

2) What time do you usually go to bed?

3) What time do you usually go to sleep?

4) What time do you usually wake up?

5) What time do you usually get up?

6) Do you have to be woken in the morning YES NO YES NO

(by someone else, an alarm clock etc)?

7) Do you usually wake up in the morning YES NO YES NO

well rested?

8) Do you usually wake up in the morning YES NO YES NO

feeling quite tired?

9) Do you usually wake up in a bad mood? YES NO YES NO

10) Do you usually wake up in a good mood? YES NO YES NO

11) Do you take naps during the day? YES NO YES NO

If YES, about what time do you nap and for

how long?

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PART FOUR
During the LAST ONE MONTH have you shown any of the following behaviours? Please tick
the box which describes how often each behaviour happens (it may be useful to ask your sleeping
partner, if you have one, to help you fill in these questions since you may not know about some of
the things that you do during your sleep).

Description Don’t Never About A few Once 3 – 6 Daily

know once a times or times
month a twice a
or less month a week
week

Talking in sleep

Walking in sleep

Grinding teeth in sleep

Banging head at night

Quick movements of arms or legs during sleep

(e.g. kicking, jumping, arm flailing)

Moving around a lot in bed during sleep (restless

sleep)

Biting tongue during sleep

Snoring loudly during sleep

Gagging, choking, or snorting loudly during

sleep

Seem to repeatedly stop breathing for periods of

time lasting up to 30 seconds during sleep

Getting up to use the toilet in the night

Wetting bed during sleep

Waking in night complaining of nightmares or

frightening dreams and feel quite anxious. This
usually happens in the last half the night

Waking during the night screaming in terror.

Anxiety may be so bad that sweating, gasping or
trembling may happen. This usually happens
during the first half of the night. Not aware of
surroundings and will not remember it the next
day.

Not wanting to go to bed because you are afraid.

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Description Don’t Never About A few Once 3 – 6 Daily
know once a times or times
month a twice a
or less month a week
week

Fearing that if you go to sleep you might die

Afraid of the dark

Aching legs / leg cramps

Insisting on bedtime rituals (e.g. Doing certain

things in a special certain order) before sleep

Needing sleeping medication

During the day, muscles become so weak that

you fall to the ground or have to lie down before
falling (usually after laughing, crying or being
frightened)

Upon waking or going off to sleep, feeling

paralysed even though you are aware of your
surroundings

During the day, have urges to go to sleep and

cant stop yourself

Feeling drowsy during the day, but can stop

yourself from sleeping

During the day, appearing more active than other

people

Rolling from side to side rhythmically in sleep or

while going off to sleep

Sleeping with head tipped right back

Breathing through mouth rather than nose when

asleep

Complaining of headaches on waking up

Sweating a lot during sleep

Pain interfering with sleep

Waking in the morning before 5am and staying

awake.

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PART FIVE
This section asks some questions about the family’s sleep and also treatments for sleep problems
you might have tried. Please circle either YES or NO and, where appropriate, write your answer.

1) Have you ever had any advice or treatment for your sleep? YES NO
If YES, please describe.

2) Was this advice or treatment helpful? YES NO

3) How severe do you consider your sleep problems to be? Mild ( )

Moderate ( )
Severe ( )

4) Are other members of the family affected by your sleep pattern? YES NO
Please describe who and how they are affected.

5) Has anyone on either side of the family had any sleep problems (e.g. Nightmares, sleepwalking,
night terrors, unusual jerks, or movements, or other attacks)? If so, please describe and state
their relationship to you.

6) Is there anything else about your sleep, or anything else, that you think is important and we have
not mentioned? Please give details below.

Thank you very much for completing this questionnaire

Sleep Disorders Clinic

Department of Clinical Neurophysiology, Level 3 – West Wing,
John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU