The following questions have been designed to help identify problems with your sleep. Please answer them as best you can. After completing the questionnaire, you will be provided information about your risk of having a sleep disorder.

First Name: (optional)     Last Name: (optional)
Gender: *Date of Birth(mm/dd/yyyy):
1. When you try to relax in the evening or sleep at night, do you ever have unpleasant, restless feelings in your legs that can be relieved by walking or movement?
2. How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? This refers to your usual way of life in recent times. Even if you have not done some of these things recently, try to work out how they would have affected you. Use the following scale to choose the most appropriate number for each situation.
  Would Never
Doze		 Slight Chance of Dozing Moderate Chance
of Dozing		 High Chance of Dozing  
a. Sitting and reading  
b. Watching TV  
c. Sitting inactive in a public place (e.g., a theater or a meeting)  
d. As a passenger in a car for an hour without a break  
e. Lying down to rest in the afternoon when circumstances permit  
f. Sitting and talking to someone  
g. Sitting quietly after lunch without alcohol  
h. In a car while stopped for a few minutes in traffic