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  Locations  
 
Palatine Heart Center
523 Old Northwest Highway,
Barrington, IL 60010
Phone (847) 381-1200
Fax (847) 381-1904
 
Heart Lung Center
360 Station Drive
Crystal Lake, IL 60014
Phone (815) 477-8900
Fax (815) 477-7160
 
 
  Global Sleep Assessment Questionnaire
Global Sleep Assessment Questionnaire:
1. Do you have difficulty falling asleep, staying asleep or do you feel poorly rested in the morning?
 
Never Sometimes Usually Always
 
2. Do you fall asleep unintentionally or fight to stay awake during the day?
 
Never Sometimes Usually Always
 
3. Do sleep difficulties or daytime sleepiness interfere with your daily activities?
 
Never Sometimes Usually Always
 
4. Do work or other activities prevent you from getting enough sleep?
 
Never Sometimes Usually Always
 
5. Do you snore loudly?
 
Never Sometimes Usually Always
 
6. Do you hold your breath, have breathing pauses or stop breathing in your sleep?
 
Never Sometimes Usually Always
 
7. Do you have restless or "crawling" feelings in your legs at night that go away if you move your legs?
 
Never Sometimes Usually Always
 
8. Do you have repeated rhythmic leg jerks or leg twitches during your sleep?
 
Never Sometimes Usually Always
 
9. Do you have nightmares or do you scream, walk, punch or kick in your sleep?
 
Never Sometimes Usually Always
 
10.

Do the following things disturb you in your sleep: pain, other physical symptoms, worries, medications or other (specify)?

 
Never Sometimes Usually Always
 
11.

Do you feel sad or anxious?

 
Never Sometimes Usually Always
 

If you have answered sometimes, usually or always to one or more of these questions, you may have an underlying sleep disorder.
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