Sleep Assessment Survey
RequiredRequired Question(s)
1.

Name:

 

50 characters left.
2.

Email:  ( so we can send you your personalized tips )

 

50 characters left.
Required 3.

How many hours do you sleep at night?

2-4 hours
5-6 hours
7-9 hours
I don't sleep through the night.
Other  
Required 4.

How often do you nap?

Not usually
2-3 times per week
Whenever I can
I can't remember
Required 5.

Do you take supplements for sleep?

No
Yes, Melatonin
Yes, Magnesium
Yes, a prescription aid
I have no trouble sleeping
Other  
Required 6.

Do you suffer from any of the following?

Daytime sleepiness
Napping
Trouble focusing or remembering things
Feeling irritable or short-tempered
Needing caffeine or other stimulants to stay awake
Craving sugar throughout the day
Trouble falling or staying asleep at night
Other  
  • Comment:

  • 500 characters left.
Required 7.

Do you drink wine after 6pm?

Yes
Yes, but only one glass
Not usually
Never
  • Comment:

  • 500 characters left.
Required 8.

Do you exercise?

Yes
Yes, at least 3-4 times per week
Yes, I walk everyday at least 10,000 steps
Yes, I walk most days
I don't have time to exercise
Other  
  • Comment:

  • 500 characters left.
Required 9.

How much alcohol do you drink in a week?

I don't drink
I have 1-2 units/glasses a week
I have 3-5 units/glasses a week
I have 6-8 units/glasses a week
Other  
Required 10.

Do you wake up at night because you have to go to the bathroom?

Every night
Sometimes
Not that I'm aware of
I don't remember
Other  
Required 11.

Thank you for sharing!  Please leave us with any additional information we should know to help you sleep better!

Leave a comment
I have everything I need
  • Comment:

  • 500 characters left.