Sleep Questionnaire

NAME: *

D.O.B: *

What sort of sleep problems do you have? *

Trouble falling asleep

Difficulty staying asleep

Waking up too early

Feeling tired and irritable during the day

How often do you have sleep problems? *

Rarely (once per month)

Sometimes (2-3 times per month)

Regularly (once per week)

Very Regularly (3+ times per week)

On average, how many hours of sleep do you get each night? *

8+

7

6

5

4

3

2

1

0

How long have you been experiencing sleep problems? *

Less than 3 months

More than 3 months

What do you struggle with during the day because of your sleep? *

Working/Studying

Exercising

Being Sociable

Caring for myself/my family

Daily Tasks

Memory / Concentration

How often do other people notice your mood is affected by your sleep problems? *

Never

Sometimes

A lot

How does your sleep make you feel? *

Happy

Content

No difference

Sad

Frustrated

Angry

Upset

What have you tried to improve your sleep? *

Nothing Yet

Healthy sleep habits (eg. limiting caffeine)

Pharmacy treatments (over-the-counter medicines or sleep aids)

Cognitive behavioural therapy for insomnia (CBT)

Meditation / Breathing exercises

Prescription Medicine

Sleepio App

Other

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Sleep Questionnaire

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