Your Name

Your Email

Your Phone Number

Do you feel rested in the morning? Do you feel rested in the morning? Yes No

Are you satisfied with your sleep? Are you satisfied with your sleep? Yes No

Do you fall asleep in less than 30 minutes? Do you fall asleep in less than 30 minutes? Yes No

Do you sleep between 6 and 8 hours per night? Do you sleep between 6 and 8 hours per night? Yes No

Do you stay awake all day without dozing? Do you stay awake all day without dozing? Yes No

Do you have a regular awakening time? (If so, when?)

Do you have a regular bed time? (If so, when?)

Are you asleep (or trying to sleep) between 2:00 a.m. and 4:00 a.m.? Are you asleep (or trying to sleep) between 2:00 a.m. and 4:00 a.m.? Yes No

Do you wake in the middle of the night? (If so, is there a regular waking time and how long are you awake?)

What have you tried (habits, supplements, etc.) to remedy sleep troubles in the past?

Do you currently have any practices that enhance the quality of your sleep? Do you currently have any practices that enhance the quality of your sleep? Yes No

What (if any) electronics are in your room at nighttime?

On a scale of 1-10 (10 being the darkest), how dark is your bedroom? On a scale of 1-10 (10 being the darkest), how dark is your bedroom? 1 2 3 4 5 6 7 8 9 10

Do you consume any stimulants during the day? If so, when?

Please identify how you would most generally categorize your sleep troubles: Please identify how you would most generally categorize your sleep troubles: MIND (racing, working, etc.) BODY (pain, discomfort, etc.) SPIRIT (depression, anxiety, etc.)

How often do you experience daytime sleepiness? How often do you experience daytime sleepiness? Never Monthly Weekly Daily

How often do you experience no dream recall? How often do you experience no dream recall? Never Monthly Weekly Daily

How often do you experience sleep walking? How often do you experience sleep walking? Never Monthly Weekly Daily

How often do you experience nightmares? How often do you experience nightmares? Never Monthly Weekly Daily

How often do you experience snoring? How often do you experience snoring? Never Monthly Weekly Daily

How often do you experience sleep apnea? How often do you experience sleep apnea? Never Monthly Weekly Daily