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Survey*

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First Name

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Last Name

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Age

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Gender

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How many children

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Email*

How is your sleep?*

Do you consider that you have trouble falling asleep?*

Yes
No

When did it start?*

How many nights per week do you have trouble falling asleep?*

Do you consider that you have trouble staying asleep?*

Yes
No

When did it start?*

Do you sleep through the night?*

Yes
Mostly
Sometimes
Never

How many nights per week do you wake up in the night?*

How many times do you wake up during the night?*

How long are you awake for?*

Minutes

Why are you waking at night? Tick all that apply*

I am waking for no reason
I am waking to go to the toilet
Other

What is the reason?*

Are you waking to go to the toilet or are you going to the toilet because you are awake?*

I am waking to go to the toilet
I am going to the toilet because I am awake

How many times are you waking during the night to pee?*

How long does it take you to fall asleep?*

Under 20 minutes
30 minutes
40 minutes
50 minutes
60 minutes or more

Do you have a relaxation wind down routine that you follow in preparation for bed?*

Yes
No

What is it?*

Do you prioritise your sleep?*

Yes
No

Up until what point before turning out the light are you interacting with technology (computer/phone).*

Up until the last second
1-5 minutes
5-20 minutes
20-30 minutes
30 or more minutes

What time do you go to bed*

What is your shift pattern?*

Are you woken easily by other people or noises?*

Yes
No
Sometimes

Do you toss and turn in your sleep?*

Yes
No
Sometimes

Do you snore, twitch or jerk yourself awake?*

Yes
No
Sometimes

Considering how you feel within 30 minutes of waking, how do you feel?*

Tired
Somewhat refreshed
Refreshed

Are you experiencing stress?*

Yes
No

On a scale of 1 to 10 (1 being low and 10 being high) how would you rate your current stress level?*

When did it start? You don’t have to be exact.*

Has your sleep been affected by your stress?*

Yes
No

Do you feel you are able to manage your stress?*

Yes
No

Have you previously experienced long term stress?*

Yes
No

On a scale of 1 to 10 (1 being low and 10 being high) how would you rate your previous stress level?*

When did it start? You don’t have to be exact.*

When did it end? You don’t have to be exact.*

Has your sleep been affected by your previous long term stress?*

Yes
No

Considering your energy throughout the day. How would you rate your energy?(1 being can’t get out of bed, 10 being “I can take on the world”)*

Do you get tired during the day?*

Never
Sometimes
Often
All the time

I get tired in the:*

Morning
Day
Afternoon
Evening

Tick all that apply

On a scale of 1 to 10 (1 being not so much and 10 being very much) how would you rate the impact your lack of sleep is having on your sex drive:*

Ability to socialize:*

Family time:*

Experiencing food cravings or making poor food choices:*

Quality of life:*

Performance at work:*

Do you believe your lack of sleep contributes to:*

Memory
Focus
Concentrating on tasks
NONE APPLY

tick all that apply

Do you believe your hormones are impacting on your sleep?*

Yes
No

Is it period cycle related?*

Yes
No

Is it perimenopause / menopause related?*

Yes
No

Do you have any other sleep related comments?*

Yes
No

Comments:*

Sleep Health Index

National Sleep Foundation – Health Sleep Index Questionnaire

Step 1 of 6 - Personal Information

Sleep Health Index

National Sleep Foundation – Health Sleep Index Questionnaire

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