sleep symptom checklist - Amazon AWS

SLEEP SYMPTOM CHECKLIST FOR THE PATIENT

SEVERITY

Notes :

For each symptom, check () how SEVERE i twas during the past month 0 = not at all 1 = mildly 2 = moderately 3 = very Waking up and trouble getting back to sleep Insomnia Trouble falling asleep Poor sleep quality Waking up too early in the morning Waking often to urinate Daytime sleepiness Lack of vitality or energy Bodily pain Daytime fatigue Limited in doing things because of health Sleep is non-refreshing Waking with a headache Snoring Interruption of breathing during sleep Legs or arms jerk at night Falling asleep during the day when not wanted Waking with a dry mouth Discomfort in legs with strong urge to move Depression Anxiety Poor emotional well-being

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Source : © Sally Bailes. Reproduction autorisée.