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Sleep Assessment

A quick assessment to understand your current sleep habits.

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Question 1 of 15

Are you satisfied with your sleep?

A

Yes

B

No

Question 2 of 15

Do you feel rested in the morning?

A

Yes

B

No

Question 3 of 15

Do you stay awake all day without dozing?

A

Yes

B

No

Question 4 of 15

Do you fall asleep in less than 30 minutes?

A

Yes

B

No

Question 5 of 15

Do you sleep between 6 & 8 hours per night?

A

Yes

B

No

Question 6 of 15

Do you have a regular bedtime? (If so, what time?)

Question 7 of 15

Do you wake consistently each day at the same time? (If so, what time?)

Question 8 of 15

Do you wake in the middle of the night?  (If so, is there a regular waking time and how long are you awake?)

Question 9 of 15

Are you asleep between 2:00 am and 4:00 am?

A

Yes

B

No

Question 10 of 15

Do you currently have any practices that enhance your quality of sleep?

A

Yes

B

No

Question 11 of 15

What have you tried (habits, supplements, etc.) to remedy sleep troubles in the past?

Question 12 of 15

What electronics are in your room at nighttime?

Question 13 of 15

On a scale of 1-10, how dark is your bedroom? (10 being darkest)

Question 14 of 15

Do you consume any stimulants during the day? (coffee, teas, energy drinks, soda, drink flavor enhancers, chocolate, dietary supplements) If so, when are you taking them?

Question 15 of 15

Please identify how you would categorize your sleep troubles:

(Select all that apply)
A

MIND (Racing, working, etc.)

B

BODY (pain, discomfort, etc.)

C

SPIRIT (depression, anxiety, etc.)

D

I have none of these troubles

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