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.
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.
| COMPLETE HEALTH Chiropractic Clinical Nutrition Rehab |
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| Call Today 972-735-0707 |
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