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Natural Supplements
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Contact Us
Sleep Optimization Questionnaire
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Sleep Optimization Questionnaire
Sleep Optimization Questionnaire
Sleep Optimization Questionnaire
Step
1
of
2
50%
1. Please rate the current (i.e., last 2 weeks)
SEVERITY
of your insomnia problem(s).
Difficulty falling asleep:
(Required)
(0) None
(1) Mild
(2) Moderate
(3) Severe
(4) Very
Difficulty staying asleep:
(Required)
(0) None
(1) Mild
(2) Moderate
(3) Severe
(4) Very
Problem waking up too early:
(Required)
(0) None
(1) Mild
(2) Moderate
(3) Severe
(4) Very
2. How SATISFIED/dissatisfied are you with your current sleep pattern?
(Required)
0 = Very Satisfied, 4 = Very Dissatisfied
0
1
2
3
4
3. To what extent do you consider your sleep problem to INTERFERE with your daily functioning (e.g. daytime fatigue, ability to function at work/daily chores, concentration, memory, mood, etc.).
(Required)
(0) Not at all Interfering
(1) A little
(2) Somewhat
(3) Much
(4) Very Much Interfering
3. To what extent do you consider your sleep problem to INTERFERE with your daily functioning (e.g. daytime fatigue, ability to function at work/daily chores, concentration, memory, mood, etc.).
(Required)
(0) Not at all Interfering
(1) A little
(2) Somewhat
(3) Much
(4) Very Much Interfering
4. How NOTICEABLE to others do you think your sleeping problem is in terms of impairing the quality of your life?
(Required)
(0) Not at all Noticeable
(1) Barely
(2) Somewhat
(3) Much
(4) Very Much Noticeable
5. How WORRIED/distressed are you about your current sleep problem?
(Required)
(0) Not at all
(1) A little
(2) Somewhat
(3) Much
(4) Very Much
Name
(Required)
First
Last
Email
(Required)
Phone
(Required)
Date of Birth
(Required)
MM slash DD slash YYYY
CAPTCHA
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