Age: _________ Gender: M / F
1. How long does it usually take you to fall asleep?
a) 0 - 5 minutes
b) 5 - 15 minutes
c) 15 - 30 minutes
d) More than 30 min.
2. On the average, how many times do you wake up during the night (circle the correct response)?
None, 1, 2, 3, 4, 5, 6, more than 6
3. Why do you wake up during the night?
a) nature calls
b) dreams or nightmares
c) external noise
4. How many hours of sleep do you normally get each night?
a) 4 or less
b) 4 - 6
c) 6 - 8
d) 8 - 10
e) More than 10
5. Have you been diagnosed with a sleep disorder?
If so, please name it:
6. How are you treating the sleep disorder (circle all that apply):
a) nonprescription sleeping product
b) prescription drug
c) light therapy
d) mechanical device
e) no treatment
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