Last Night’s Sleep Please enable JavaScript in your browser to complete this form.Today's Date:Current Sleep Evaluation (Check All that Apply)Difficulty breathing when asleep Stop breathing during sleepLoud SnoringRestless sleepSweating when sleepingDaytime sleepiness Poor appetiteNightmaresSleepwalking Sleep talking Screaming in sleepKick legs in sleep Wake up at night Get out of bed at night Trouble staying in bed Resist going to bed at bedtimeGrind teeth Uncomfortable feeling in legsHow Would You Characterize Your Sleep Last Night (scale 1:10; 1 Being poor, 10 equals Great!)Rate 1 out of 10Rate 2 out of 10Rate 3 out of 10Rate 4 out of 10Rate 5 out of 10Rate 6 out of 10Rate 7 out of 10Rate 8 out of 10Rate 9 out of 10Rate 10 out of 10How Did You Feel Upon Awakening? (scale 1:10; 1 Being Extreme Fatigue, 10 equals Great!) (copy)Rate 1 out of 10Rate 2 out of 10Rate 3 out of 10Rate 4 out of 10Rate 5 out of 10Rate 6 out of 10Rate 7 out of 10Rate 8 out of 10Rate 9 out of 10Rate 10 out of 10How Many Times Did You Awaken & Get Out of Bed (scale 1:5; 1 equals none, 5 >five times)Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5Did You Have Trouble Falling Asleep? (scale 1:10; 1 being No Problem; 10 equals Failed to Sleep)Rate 1 out of 10Rate 2 out of 10Rate 3 out of 10Rate 4 out of 10Rate 5 out of 10Rate 6 out of 10Rate 7 out of 10Rate 8 out of 10Rate 9 out of 10Rate 10 out of 10Last Evening's Bed TimeTime Out-of-BedSubmit