1. What sleep disorder(s) do you have? (Check all that apply.)

insomnia	narcolepsy	talking in sleep
teeth grinding	snoring	nocturnal asthma
Restless Legs Syndrome or Periodic Limb Movement	REM sleep disorder	bedwetting
night terrors	sleepwalking	daytime sleepiness
advanced or delayed sleep phase syndrome	Chronic Fatigue Syndrome and/or Fibromyalgia	other (see #2)

Diagnosed? Yes ______ No ______ Diagnosis uncertain /pending ______

2. Please name any other disorder(s) or disease(s) which you have.

3. How long have you had sleep problems?

4. What are the main difficulties you find with your disorder(s)?

5. Please share anything which you've found helpful as treatments or coping skills.