Cognitive Neuroscience lab - Sleep Questionaire

Sleep Questionaire

Please fill in all fields unless stated otherwise.

Name
NRIC Number
Phone
E-mail
Age
Gender	Male Female
Are You Right Handed?	Yes No
Occupation	State current level of education if schooling

Do you have any language impairments? No Yes If yes, please specify

First Language? English Chinese Malay Tamil Others If others, please specify

Second Language? (Must differ from First Language) English Chinese Malay Tamil Others If others, please specify

Do you have metallic implants?
No Yes Maybe	Vascular Clips Pacemakers Replacement Joints Skull Plates Braces / Dental Retainers Others If others, please specify

Do you have any history of neurological or psychiatric disorders? No Yes If yes, please specify

Do you have any chronic medical illnesses? No Yes If yes, please specify

Are you on any long term medications? No Yes If yes, please specify

Do you suffer from any of the following problems?
Sleep Apnea	NoYes
Narcolepsy	NoYes
Periodic Leg Movements	NoYes
Excessive Daytime Sleepiness	NoYes
Insomnia	NoYes