Personal Sleep Assessment

Full Name*

First NameLast Name

Gender*

FemaleMale

E-mail*

Confirmation Email

Phone Number*

How did you hear about us?

Please describe your sleep trouble?*

1. How many nights per week do you usually have difficulty falling asleep?*

2. On these nights how long does it usually take you to fall asleep after going to bed?*

3. How many nights per week do you wake up in the middle of the night and have difficulty falling back to sleep?*

3a. On the average, how many times do you wake up on these nights?

3b. How long are you awake during the night?

4. How often do you wake up early in the morning, before your scheduled wake time, and are unable to return to sleep?

5. On nights when you have insomnia, approximately how long do you sleep each night?*

6. On nights when you don't have insomnia, how long do you sleep?*

7. How long would you like to be able to sleep each night?*

8. How long have you had sleep problems?*

9. Are your sleep problem sometimes worse than other times?*

10. Was the onset of your sleep problem related to any specific event?*

11. What do you do to relax prior to bedtime?*

12. What time do you get into bed at night?*

12a. What time do you turn off the lights to go to sleep?*

12b. What time do you get out of bed in the morning?*

13. Do you use your bed for activities other than sleep or sexual activity?*

If yes, please describe:

14. At this time, how much stress would you say there is in your life?*

	1	2	3	4	5	6	7	8	9	10

1 is No Stress, 10 is High Stress

14a. Please list significant stressors in the past 18 months:*

14b. Have you ever been abused, the victim of a crime, or experienced a trauma?*

14c. What resources do you have for emotional support?*

15. Have you received psychological treatment (such as psychotherapy) in the past for depression, anxiety disorder (such as panic disorder) alcohol problems, or other problem?*

If yes, what were you treated for?

16. Are you currently in treatment with any of the following?*

17. Have you experienced either depressed mood or loss of interest in pleasure or pleasurable activities for a two week period in the past six months.*

18. How long have you been in therapy?

18a. How often do you go?

18a. What is the focus of treatment?

19. How often is your sleep disturbed by environmental factors such as traffic, neighbors, or family members?*

20. On weekends or your days off, do you sleep more than an hour later than your usual wake up time?*

21. How many times per week do you take naps?*

22. Do you engage in some kind of regular physical exercise?*

If yes, describe the kind, frequency, and time of day:

23. Have you previously, or do you currently, practice any type of relaxation technique?*

If yes, what type:

24. How many cups or glasses of caffeinated beverages (e.g. coffee, tea, or cola) do you drink in a day?*

	0	1	2	3	4	5	6	7	8	9	10	11 or more
Coffee
Tea
Cola
Other

25. How many days a week do you drink caffeinated beverages after 4:00 p.m.?*

26. How often do you use alcohol to aid sleep?*

27. How often and what amounts of alcohol do you drink?*

27a. Do you use recreational drugs?*

28. Does difficulty sleeping ever affect your mood or functioning during the day?*

If yes, describe how your mood or functioning is affected:

Please answer if you answered yes to question 28.

29. Are you sleepy during the day?*

30. Have you recently taken any prescription or over-the-counter medication for sleeping problems?*

30a. If yes, what medication and amount are you taking?

Please answer if you answered yes to question 30.

30b. How many nights a week do you usually take this medication?

Please answer if you answered yes to question 30.

30c. How long have you been taking sleeping medication?

Please answer if you answered yes to question 30.

31. Do you snore?*

32. Do you ever wake up in the night and feel unable to breathe?*

33. Do your legs ever jerk repeatedly or feel restless after you go to bed at night?*

34. Are you currently taking any other medication?*

34a. If yes, what medication is it?

Please answer if you answered yes to question 34.

34b. What illness was it prescribed for?

Please answer if you answered yes to question 34.

35. Is there a history of sleeping difficulties in your family?*

36. Have you previously been evaluated or treated for sleeping problems?*

If yes, describe:

Please answer if you answered yes to question 36.

37. Have you tried any self-help remedies for your sleeping problems?*

If yes, describe:

Please answer if you answered yes to question 37.

Additional info you might want to share

SLEEP HISTORY QUESTIONNAIRE