Sleep Improvement Survey

Name
Gender

Part 1: Sleep Duration and Quality:

Overall, do you…?
Feel you are getting enough sleep?
Feel you get a good night sleep?
Wake up frequently?
Wake up frequently and have trouble falling back to sleep?
Fall asleep easily but wake up soon afterwards?
Have trouble waking up in the morning?
Feel you could improve your sleep?

Part 2: Good sleep practice

Before going to bed do you…?
Drink coffee in late afternoon or early evening?
Drink alcohol after dinner?
Smoke Cigarettes?
Eat high protein foods like meat and nuts etc before bed?
Eat within 3-5 hours of going to bed?
Practice a bedtime ritual (read etc) to let your body know its time to sleep?
When really stressed have a hot bath for 10-20 mins before bed?
Got to bed even if you are not sleepy?
Have a fixed bedtime?

Part 3: Good sleep practice:

In the bedroom, do you…?
Have a bedroom clock that you can see?
Use your laptop, iPad or phone in bed before sleep?
Have 'To Do' conversations in bed before going to sleep?
If you are not asleep in 15 minutes, do you get up and go to another room & do something relaxing?
If you do get up during the night, do you eat, drink alcohol or have a cigarette?
Lie in bed and worry if you can't sleep?
Think you spend too much time in bed?
Have a fixed time to get up?
When you get up do you open your blinds or turn on the lights?

Part 4: Daytime Activity

During the day, do you…?
Have a nap of more than 30 minutes?
Avoid lying down except when you are trying to sleep?
Practice any relaxation techniques?
Lately, do you feel tense and/or anxious?
Lately, do you feel sad and/or depressed?
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