Sleep Questionnaire

Instructions

Sleep is important for healing, immunity, mood, cognition, and many other functions in your body. Please answer the following questions about your sleep as accurately and fully as possible. For “Yes” or “No” questions, please mark your

answer and provide an explanation if one is requested.

The information will help to determine whether you are getting the sleep you need and identify possible strategies to help you sleep better.

Name

Date

14. Do you wake up in the middle of the night?

Yes

If yes, how many times and for what reasons?

15. Do you have any trouble falling back asleep when you wake up during the night?

Yes

If yes, how long does it usually take you?

16. Does feeling the need to move your feet or legs at night keep you awake, or have you been diagnosed with restless legs syndrome?

Yes

17. Do you have disturbing dreams at night?

Yes

Caffeine and Other Stimulants

18. If you use any of the following stimulants, please specify how much (number of ounces, cups, etc.) per day, how many

times per day, and at what times you typically consume or use them. If you do not use the stimulant, leave it blank.

Coffee:

Regular

Decaffeinated

How much per day?

How often per day?

At what times?

Caffeinated sodas (such as Coke®, Pepsi®, Mountain Dew®):

How much per day?
How often per day?
At what times?

Energy drinks (such as Red Bull®, Monster Energy®, Rockstar®):

How much per day?
How often per day?
At what times?

Caffeinated water:

How much per day?
How often per day?
At what times?

Green tea:

How much per day?
How often per day?
At what times?

Black tea:

How much per day?
How often per day?
At what times?

Other tea:

Name of Tea:
How much per day?
How often per day?
At what times?

Chocolate:

How much per day?
How often per day?
At what times?

Coffee/espresso ice cream:

How much per day?
How often per day?
At what times?

Sudafed® or other over-the-counter cold medications:

How much per day?
How often per day?
At what times?

Alcohol:

How much per day?
How often per day?
At what times?

Other stimulant:

List Here:
How much per day?
How often per day?
At what times?

19. In the spaces below, please list what medications you currently take (if any) and at what times:

Medication:
Time of day you take it:
Medication:
Time of day you take it:
Medication:
Time of day you take it:

Stress and Stress Reduction

20. What kind of stress have you been under in the past few months?

21. What do you do for stress management?

22. Do you have a journal to write in that is near your bed?

Yes

23. Do you exercise aerobically?

Yes

If yes, what do you do?

How often per week?

What time of the day?

Bed, Pillows, and Pain

51. What type of bed do you have, and what size is it?

52. Do you wake up because of pain?

Yes

If yes, at what time and where is the pain?

53. What type of pillow is most comfortable for you?

What type of pillow have you tried that didn’t work for you?

54. Do you use body pillows?

Yes

If yes, how many?

How do you use them?