Sleep Disorder Screening

A clinical screening tool for common sleep disorders

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Important Notice

This tool provides screening information only. It does not diagnose medical conditions, recommend treatments, or replace professional medical evaluation.

Your responses will be submitted securely to Sleep Laboratory Solutions for follow-up. All processing follows our privacy policy.

I understand that this is a screening tool only and agree to proceed.

Personal Information

We'll use this to send your screening results directly to you.

Full Name Please enter your full name

Phone Number Please enter your phone number

Email Address Please enter your email address

Basic Questions

1. Age Please enter your age

2. Gender

Male Female

Please select your gender

Menstrual status *

Regular Perimenopause Post-menopause

Please select your menstrual status

3. Height (cm) Please enter your height

4. Weight (kg) Please enter your weight

5. Neck circumference (cm) (leave blank if unknown — will be estimated using BMI)

6. Known medical conditions (tick all that apply)

Diabetes Hypertension Thyroid disorder PCOS Cardiac disease Anxiety Depression Stress History of stroke None of the above

Please select at least one option

7. Current consumption (tick all that apply)

Medications Caffeine (tea/coffee/energy drinks) Alcohol Smoking/Nicotine None

Please select at least one option

8. Your work schedule

Day shift Night shift Rotating Not working Retired

Please select your work schedule

9. What is your usual sleep schedule?

Fixed Irregular / varies daily

Please select your sleep schedule

Sleep start time * Please enter sleep start time

Wake time * Please enter wake time

Average sleep hours * Please enter average sleep hours

Sleep Satisfaction & Daytime Functioning

10. How satisfied are you with your current sleep?

Very satisfied Satisfied Somewhat Dissatisfied Very dissatisfied

Please select an option

11. How satisfied are you with your daytime functioning (work, concentration, mood, or performance)?

Very satisfied Satisfied Somewhat Dissatisfied Very dissatisfied

Please select an option

12. Do you feel tired, fatigued, or sleepy during the daytime?

Yes No

Please select an option

How often? *

Rarely (≤1 day/week) Sometimes (2–3 days/week) Often (4–5 days/week) Almost daily

Please select how often

Sleep Difficulties

13. Do you have difficulty falling asleep at bedtime?

Yes No

Please select an option

How long does it take you to fall asleep? *

<30 mins 30–60 mins More than 1 hour

Please select an option

Do you wake up during the night or earlier than planned? *

Yes No

Please select an option

If you wake up at night, do you have difficulty falling back asleep? *

Yes No

Please select an option

Daytime Sleepiness

14. Do you feel excessively sleepy during the day despite adequate sleep time?

Yes No

Please select an option

Do you have difficulty waking up? *

Yes No

Please select an option

How often do you usually nap during the day? *

I don't 1–2 times 3 or more times

Please select an option

Longest nap duration *

<30 minutes 30–60 minutes More than 1 hour

Please select an option

Do you feel refreshed after naps? *

Yes No

Please select an option

Breathing During Sleep

15. Do you have a snoring problem / has someone told you about snoring?

Yes No

Please select an option

Has anyone observed you stop breathing, choke, or gasp during sleep? *

Yes No

Please select an option

Has your snoring ever been loud enough to be heard outside the room? *

Yes No

Please select an option

Do you wake up multiple times at night or more than 3 times? *

Yes No

Please select an option

Do you wake up with a headache? *

Yes No

Please select an option

Do you wake up with dry mouth? *

Yes No

Please select an option

Sleep Timing & Rhythm

16. Do you struggle to fall asleep at conventional bedtime (10–11 PM)?

Yes No

Please select an option

Are you an *

Early riser A person who sleeps late Irregular sleeper

Please select an option

Do you feel zoned out / lost / brain fog after waking up? *

Yes No

Please select an option

During holidays/weekends does your sleep timing shift later or earlier compared to workdays? *

Yes No

Please select an option

Duration

How long have you been experiencing these signs?

Less than 2 weeks 2 weeks to 3 months 3 months to 1 year More than 1 year

Please select an option

🩺 Screening Results

Patient Details

Your responses were analyzed for patterns associated with common sleep disorders. This screening does not provide a diagnosis.

Primary Screening Finding

Additional Findings

⚠️ Possible Overlap / Comorbid Sleep Conditions

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Recommendation

If any disorder shows Moderate or High risk, we recommend consulting a qualified sleep medicine specialist or healthcare professional for a comprehensive evaluation.

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Medical Disclaimer

This tool provides screening information only. It does not diagnose medical conditions. It does not recommend treatments. It does not replace professional medical evaluation.