Yes No
|
1. Are you extremely sleepy during the day?
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Yes No
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2. Do you fall asleep during work, dinner, or while entertaining friends?
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Yes No
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3. Do you snore loudly at night?
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Yes No
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4. Do you stop breathing for short periods at night?
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Yes No
|
5. Do you wake up frequently at night?
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Yes No
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6. Are you restless at night (do you hit, kick, or slap your bed partner)?
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Yes No
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7. Do you walk in your sleep?
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Yes No
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8. Do you wet the bed?
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Yes No
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9. Do you have morning headaches?
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Yes No
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10. Are you confused when you wake up and have great difficulty "getting going"?
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Yes No
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11. Have family or friends complained about disturbing changes in your personality?
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Yes No
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12. Do you occasionally forget about tasks you've already finished?
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Yes No
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13. Do you sometimes see things that aren't there (hallucinations)?
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Yes No
|
14. Do you have trouble maintaining attention and concentrating?
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Yes No
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15. Do you have "spells" when you unexpectedly drop things?
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Yes No
|
16. Do you ever feel unable to move (or paralyzed) just before you fall asleep or wake up?
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Yes No
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17. Do you have insomnia?
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Yes No
|
18. Do you have a problem with impotence?
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Yes No
|
19. Have you gained more than 10 pounds in the past year?
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Yes No
|
20. Do you wake up in the middle of the night with heartburn? |