Narcolepsy Questionnaire

Manse Medical's Narcolepsy Questionnaire

This is the Ullanlinna scale used to validate people who have narcolepsy with cataplexy.

First Name *

Last Name *

Date of Birth *

Phone Number *

Email *

1) When laughing, feeling glad or angry, or in an exciting situation, have the below symptoms suddenly occurred?

NeverOne to five times during lifetimeMonthlyWeekly Daily or almost daily

Knees buckling

NeverOne to five times during lifetimeMonthlyWeekly Daily or almost daily

Mouth opening

NeverOne to five times during lifetimeMonthlyWeekly Daily or almost daily

Head nodding

NeverOne to five times during lifetimeMonthlyWeekly Daily or almost daily

Falling down

NeverOne to five times during lifetimeMonthlyWeekly Daily or almost daily

2) How fast do you fall asleep in the evening? *

Greater than 40 minutes 31 - 40 minutes21 - 30 minutes10 - 20 minutesLess than 10 minutes

3) Do you take naps during the day? *

No needI want to but cannot sleepTwo days or less each weekThree to five days each weekSix to seven days each week

4) Do you fall asleep unintentionally during the day while doing the following?

NeverOne to five times during lifetimeMonthlyWeekly Daily or almost daily

Reading

NeverOne to five times during lifetimeMonthlyWeekly Daily or almost daily

Travelling

NeverOne to five times during lifetimeMonthlyWeekly Daily or almost daily

Standing

NeverOne to five times during lifetimeMonthlyWeekly Daily or almost daily

Eating

NeverOne to five times during lifetimeMonthlyWeekly Daily or almost daily

Other unusual times

NeverOne to five times during lifetimeMonthlyWeekly Daily or almost daily

Your score is:

A total score above 14 is suggestive of Narcolepsy with Cataplexy. However, if you are experiencing symptoms listed in this questionnaire, we will email you instructions on how to book a complimentary call with our Narcolepsy Connect Program Coordinator. There is no charge for this call.

And we're done! Your responses will be emailed to you and Manse Medical.

I consent for Manse Medical to send marketing communication that may be relevant to me such as clinic updates, promotions and service information.I consent for Manse Medical to use the data provided in this questionnaire in an unidentifiable manner for research and development purposes.

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