Sleep Suervey

Welcome to your Sleep Survey

Email (Required)

Name *

Family *

These questions pertain to your typical sleep patterns over the last month. Please respond based on the most accurate representation of your habits for the majority of days and nights during this period. Answer all questions.

1.In the last month, what time have you typically gone to bed at night?Your usual bedtime: (* Required)

2. In the last month, how many minutes has it usually taken you to fall asleep each night? (*)

3. In the last month, how many hours of actual sleep did you typically get at night? (This may differ from the number of hours you spent in bed).Hours of sleep/night: (*)

Select the most appropriate response for each of the following questions. Be sure to answer all questions.

a) How often have you struggled to fall asleep within 30 minutes? (*)

Not during the past month

Less than once a week

Once or twice a week

Three or more times a week

b) How often have you experienced waking up in the middle of the night or early morning? (*)

Not during the past month

Less than once a week

Once or twice a week

Three or more times a week

c) How often have you had to get up to use the bathroom during the night? (*)

Not during the past month

Less than once a week

Once or twice a week

Three or more times a week

d) Have you experienced difficulty breathing comfortably? (*)

Not during the past month

Less than once a week

Once or twice a week

Three or more times a week

e) Have you coughed or snored loudly during sleep? (*)

Not during the past month

Less than once a week

Once or twice a week

Three or more times a week

f) Have you had bad dreams? (*)

Not during the past month

Less than once a week

Once or twice a week

Three or more times a week

g) Have you felt excessively hot? (*)

Not during the past month

Less than once a week

Once or twice a week

Three or more times a week

h) How often have you experienced pain? (*)

Not during the past month

Less than once a week

Once or twice a week

Three or more times a week

i) How frequently have you experienced difficulty staying awake while driving, eating meals, or engaging in social activities? (*)

Not during the past month

Less than once a week

Once or twice a week

Three or more times a week

j) How much of a challenge has it been for you to maintain enough enthusiasm to get things done? (*)

Not a problem at all

Only a very slight problem

Somewhat of a problem

A very big problem

k) How frequently have you used medication (prescribed or over-the-counter) to aid your sleep? (*)

Not during the past month

Less than once a week

Once or twice a week

Three or more times a week

l) In the last month, how would you assess your overall sleep quality? (*)

Very good

Fairly good

Fairly bad

Very bad

Other reason(s): reasons that made you have difficulty sleeping during last month

Do you have a room-mate (RM) or bed partner (BP)? (*)

No RM or same BP,

RM or BP in same room

Partner in room different bed

Partner in bed

If you have a room-mate or bed partner, ask him/her how often in the past month you have had …

a) Loud snoring (*)

Not during the past month

Less than once a week

once or twice a week

three or more times a week

b) Long pauses between breaths while sleeping (*)

Not during the past month

Less than once a week

once or twice a week

three or more times a week

c) Legs twitching or jerking while you sleep (*)

Not during the past month

Less than once a week

once or twice a week

three or more times a week

d) Episodes of disorientation or confusion during sleep (*)

Not during the past month

Less than once a week

once or twice a week

three or more times a week

Other restlessness while you sleep, please describe

Indicate the likelihood of you dozing off or falling asleep in the following situations using the scale provided:

Sitting and reading: (*)

Would never doze

Slight chance of dozing

Moderate chance of dozing

High chance of dozing

Watching TV: (*)

Would never doze

Slight chance of dozing

Moderate chance of dozing

High chance of dozing

Sitting inactive in a public place (i.e. a theatre or meeting): (*)

Would never doze

Slight chance of dozing

Moderate chance of dozing

High chance of dozing

As a passenger in a car for an hour without a break: (*)

Would never doze

Slight chance of dozing

Moderate chance of dozing

High chance of dozing

Lying down to rest in the afternoon: (*)

Would never doze

Slight chance of dozing

Moderate chance of dozing

High chance of dozing

Sitting and talking to someone: (*)

Would never doze

Slight chance of dozing

Moderate chance of dozing

High chance of dozing

Sitting quietly after lunch with no alcohol: (*)

Would never doze

Slight chance of dozing

Moderate chance of dozing

High chance of dozing

In a car while stopped for a few minutes in traffic: (*)

Would never doze

Slight chance of dozing

Moderate chance of dozing

High chance of dozing

We now require information regarding the severity of your sleep-related concerns.

Please indicate the severity of your sleep-related issues by circling the appropriate number:
( None 0 | Moderate 1 | Severe 2 | Very Severe 3 )

Difficulty falling asleep (*)

None

Moderate

Severe

Very Severe

Difficulty staying asleep (*)

None

Moderate

Severe

Very Severe

Problem waking up too early (*)

None

Moderate

Severe

Very Severe

2. Please express your satisfaction with your current sleep pattern by marking the appropriate number: (*)

0 : Very Satisfied

4 : Very Dissatisfied

3. To what extent do you perceive your sleep problem as affecting your daily functioning (e.g., daytime fatigue, work/chores, concentration, memory, mood, etc.)? (*)

Not at all

A little

Somewhat

Much

Very much

4. To what extent do you believe your sleeping problem is noticeable to others in terms of your quality of life? (*)

Not at all

A little

Somewhat

Much

Very much

5. Indicate your level of worry or distress regarding your current sleep problem: (*)

Not at all

A little

Somewhat

Much

Very much

Lastly, could you please let us know what you're hoping to achieve through your treatment in the Sleep Program? (*)

Welcome to your Sleep Survey

If you have a room-mate or bed partner, ask him/her how often in the past month you have had …

Indicate the likelihood of you dozing off or falling asleep in the following situations using the scale provided:

We now require information regarding the severity of your sleep-related concerns.

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