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Sleep Test: Questions 1) I try to eat foods that are high in protein before I attempt to sleep. Very Often Often Some Rarely 2) I eat foods such as cereals, pasta, potatoes, or rice for my last meal of the day. Usually Some Rarely Never 3) I enjoy eating a big breakfast. Strongly agree Agree Slightly agree Disagree 4) I often go to bed with a growling stomach. Strongly agree Agree Slightly agree Disagree 5) I continue to in-take caffeine past early afternoon. I am addicted to caffeine. I may be addicted to caffeine. I occasionally have caffeine past early afternoon. I rarely have caffeine past early afternoon. 6) I have the tendency to have an alcoholic drink before bedtime. Strongly agree Agree Slightly agree Disagree 7) I often smoke cigarettes or am around secondhand cigarette smoke. Definitely Probably Some Rarely 8) I regularly participate in various activities for exercise. Very Often Often Some Rarely 9) I have made my bedroom as sound and light-proof as possible. I cannot hear any sound or see any light. I may hear some sound and see some light. I can hear many sounds and see much light. I have not had the opportunity to sound and light-proof my bedroom. 10) I attempt to receive at least a small amount of sunlight everyday. I love sunlight. I like sunlight. I occasionally receive sunlight. I rarely receive sunlight. 11) When I get into a pattern of waking up too early, I reset my "body clock." Definitely Some Occasionally Rarely 12) I view myself as a "night owl" because I stay up late at night. I often stay up very late. I usually stay up late. I occasionally stay up late. I rarely stay up late. 13) I often practice relaxation techniques. I am a master of relaxation techniques. I am good at relaxation techniques. I am decent at relaxation techniques. I rarely practice relaxation techniques. 14) I feel that I may be suffering from "burnout." Definitely Probably Maybe No 15) I feel that I have a high-achieving personality. I definitely have a high-achieving personality. I probably have a high-achieving personality. I may occasionally have a high-achieving personality. I do not have a high-achieving personality. 16) I am the type of person who enjoys a good laugh. Very Often Often Some Rarely 17) My pets sleep in my bed at night. Yes, they usually. They occasionally do. They rarely do. Never, or I have no pets. 18) The colors of my bedroom are... Very restful and pleasant. Comfortable. I can tolerate them. Horrible and irritating. I've been meaning to change them. 19) I try to have some form of air movement in my bedroom. Very Often Often Some Rarely 20) My bedroom is usually very clean. Yes! I keep it very clean. It is usually clean. It is occasionally clean. No! It is always cluttered. 21) I have headaches when I wake up in the morning. Very Often Often Some Rarely 22) I have a difficult time falling asleep. It is extremely difficult. It is difficult. It is slightly difficult. It is not difficult. 23) I anticipate that I will have problems falling asleep several times a week. Definitely Some Maybe No 24) If I wake up in the middle of the night, I cannot go back to sleep. Very Often Often Some Rarely 25) I have been told that I snore when I am asleep. Often Some Rarely Never 26) I have suddenly awakened, gasping for my breath. Yes, it frequently happens It has occasionally occurred It rarely occurs No, I have never experienced that 27) I have awakened with a dry mouth. Very Often Often Some Rarely 28) When I am awake, I feel like I am in a daze. I feel dazed very often. I often feel like I am in a daze. I occasionally feel like I am in a daze. I rarely feel like I am in a daze. 29) I have awakened with burning chest pain. Very Often Often Some Rarely 30) I usually cough or wheeze at night when trying to sleep. Yes! I sound horrible. I occasionally cough or wheeze. I rarely cough or wheeze. No, I do not cough or wheeze. 31) I often have pain or discomfort in my chest or throat that makes it difficult for me to fall asleep. It is extremely difficult. It is difficult. It is slightly difficult. No, I do not experience that. 32) I awake at night with an acid or sour taste in my mouth. Very Often Often Some Rarely 33) I have "sleep attacks" during the day, regardless of how hard I try to stay awake. Often Some Rarely Never 34) I have experienced moments of feeling paralyzed during my sleep. Yes! I often have this experience. I occasionally have this experience. I rarely have this experience. No, I have not had that experience. 35) I often wish that I had more energy. Definitely Some Rarely Never 36) If I am angered or surprised, I feel like my muscles go limp. Yes! I cannot move. I have occasionally felt like I could not move. I have rarely felt like I could not move. I have never felt like I couldn't move. 37) I have been told that parts of my body jerk while I am asleep. My body jerked wildly. My body had some movement. My body had little movement. My body had no movement. 38) I have been told that I kick while I am sleeping. Yes! I should take karate. I kick some. I kick very little. I do not kick while sleeping. 39) I occasionally find it difficult to keep my legs still at night, since moving them makes me feel comfortable. Yes Some Maybe No 40) Even if I sleep during the night, I still feel sleepy during the day. Definitely Some Occasionally Rarely 41) I sweat excessively while I am asleep. Often Some Rarely Never 42) I have noticed my heart pounding or beating irregularly while trying to sleep. Yes! It happens quite often. It happens occasionally. It rarely happens. No, I have never experienced that. 43) I often worry about various things, which makes me unable to relax. Yes! I am a nervous wreck! I occasionally worry about various things. I rarely worry about various things. No, I do not usually worry about various things. 44) While sleeping, I have awakened feeling like I am choking. Often Some Rarely Never 45) I have trouble at work due to my sleepiness. I doze off at work. I can barely keep my eyes open. I am slightly sleepy. I do not have any problems with sleepiness at work. 46) My family, friends, and co-workers have told me that I am often irritable and grumpy. Yes, they tell me that I am irritable and grumpy very often. They often tell me that I am irritable and grumpy. They occasionally tell me that I am irritable and grumpy. They rarely tell me that I am irritable and grumpy. 47) I feel I experience a persistent pattern of sleep disruption. Definitely Some Maybe No 48) I feel that my sleep-wake pattern is backwards. Definitely Probably Maybe No 49) I feel like I am losing my sex drive. Yes, I am on empty. I feel that I might be losing my sex drive. I occasionally feel like I am losing my sex drive. No, I am not losing my sex drive. 50) I struggle with feeling sad and depressed. I am often very sad and depressed. I am usually sad and depressed. I am occasionally sad and depressed. I am rarely sad and depressed. 51) I struggle with thoughts racing through my mind, which prevents me from sleeping. Very Often Often Some Rarely 52) I have recently experienced significant weight gain or weight loss. Definitely Some Maybe No 53) I have difficulty concentrating at work or school. Extreme difficulty Some difficulty Slightly difficulty No difficulty 54) Other than during exercise activities, I experience muscle tension in my legs. Very Often Often Some Rarely 55) I have been told that I walk in my sleep. Yes! I walk enough to be in a marathon. I do much walking in my sleep. I do some walking in my sleep. No, I do not walk in my sleep. 56) I have awakened myself from sleep by screaming. Very Often Often Some Rarely 57) I feel that I have a shallower, fragmented sleep compared to normal sleep. Yes! I awaken easily. I often feel this way. I occasionally feel this way. I rarely feel this way. 58) I feel that I have had an increase of awakenings in the second half of the night. Definitely Some Maybe No 59) I have a high tolerance for prescription drugs. A very high tolerance A high tolerance Somewhat of a tolerance Low tolerance 60) When I have difficulty sleeping, it seems to help if I change my sleeping environment. Definitely Some Maybe No

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