Free Sleep Evaluation for Insomnia and Other Sleep Disorders

Sleep Evaluation
If you would like Dr. Webster to look at your sleep evaluation, copy and paste it into an email
with your answers and additional comments and send it to webster.completehealth@hotmail.
com

Name__________________ Date___________

1. How long does it typically take you to fall asleep at night?
A. 0-5 min.          B. 5-15 min.             C. 15-30 min.        D. 30-60        E. 60+ min.

2. When do you regularly wake up at night?
A. Never/only to go to the bathroom       B. Yes, 1:00-2:00      C. Yes, 3:00-4:00

3. Is it difficult to get going in the morning due to grogginess or fatigue?
No                Yes

4. Are you sleepy during the day?
No                Yes

5. Do you snore loudly?
No                Yes

6. Are you overweight?
No                Yes

7. Has anyone witnessed you sleeping noticed you stop breathing for several seconds?
No                Yes

8. Do you wake up with a sore throat or headache very often?
No                Yes

9. Do your arms or legs jerk when you’re in bed?
No                Yes

10. Do you have uncomfortable, tingly, achy or creepy-crawly feelings in your legs when you lie down?
No                Yes

11. Do you grind your teeth or clinch your jaw while sleeping?
No                Yes

12. How do you dream?
A. Don’t remember        B. Short dreams       C. Long epic dreams      D. Nightmares

13. When do you first get hungry in the morning?
A. Immediately         B. 30 min. to 2hrs after rising            C. 2hrs or more after rising

14. For Women- Are you awaked from night sweats or from being too hot?
No                Yes

Dr. Webster will promptly respond to it with treatment recommendations. You may also call for
an appointment with Dr. Webster at
972-735-0707.