Online Survey: Sleep


Please provide the answer that best describes your current situation.

Age:
Sex:
Marital status:

Work status:

Work hours:

What time during the 24 hour day do you sleep?

Number of children in household:

Ages of children:

Do any member of household routinely wake you or keep you awake at night? (Ex. snoring bedpartner, fussy baby who sleeps during the day and is always awake at night, invalid elderly parent needing frequent care at night, etc.)


Stress levels

Please rate stress levels from 1-10. 1=no stress, 2=very little stress, 3=little stress, 4=some stress, 5= moderate stress, 6= little more than moderate stress, 7=a lot of stress, 8=great amount of stress, 9= extreme amount of stress, 10= unbearable amount of stress.


marital relationship:

family relationships (immediate family):

extended family relationships:

relationship with friends:

your work:

spouse's or parnter's work:

overall life:

Do you find yourself unable to go to sleep often (more than 2 times per month) due to stress or worries?

Do you take sleeping pills more than 1 time per month?
If yes, how many times on average per month?


Any recent or unsual changes in your life that has changed your daily routine within the last 6 months?

stress levels: 1=no stress, 2=very little stress,3=little stress, 4=some stress, 5=moderate stress, 6=little more than moderate stress, 7=a lot of stress, 8=great amount of stress, 9=extreme amount of stress, 10=unbearable amount of stress

How long does it usually take you to fall asleep when you go to bed (at night or your longest period of sleep)?

Do you feel refreshed and ready for the day upon awakening from sleep?

Do you feel stiff when you wake up or first get out of bed?

How long does this stiffness last?

Do you usually feel pain when you wake up or first get out of bed?
Where is the pain?
How long does this pain last?

How many times do you usually wake up at night?

Check the things that usually wake you up at night:

Pain

Hungry stomach

Children or pets in the home

Night sweats or hot flashes

Muscle cramps in legs

Muscle cramps in other parts of body

Anxiety or panic attacks

Full bladder/ need to go to bathroom

Snoring bed partner

Worries/ life's problems

Unable to sleep (insomnia)

Dreams/ Nightmares

Feel as if your breath is taken away or briefly stop breathing

Heartburn, indigestion or chest pains

Bedroom too hot or too cold

Noises outside your home (ex. storms, traffic)

Noises inside your home (ex. heater, air conditioner, someone flushing toilet)

How long does it usually take you to go back to sleep after you are awaken from your sleep?

Do you consider yourself a light sleeper?

Do you sleep lighter than you did when you were a few years younger?

How do you consider you sleep at night (or longest period of sleep)

Please rate how often you experience sleepiness or drowsiness in the following situations. Rating scale: 1=never sleepy, 2=occasionally sleepy, 3=sleepy about half the time in this situation, 4=get sleepy most of the time, 5=definitely fall asleep or nod off majority if not all the time.

Reading an enjoyable book, magazine or artical

Reading a text book or something as course or work assignment or to kill time while waiting (ex. at the doctor's office or garage)

Watching TV

Sitting at a conference, workshop, meeting, church service, or movie theater

While driving a car for over an hour without a break

While riding in a car for over an hour without a break

While sitting in the car stopped in traffic

While laying down in the afternnoon to rest

An hour after you eat lunch or a big meal (when you had no alcohol)

While sitting doing paper work

Before you eat when you feel hungry

Sitting & talking to someone

When you feel bored for longer than 15 minutes

While you are working at your job

Please rate how often you experience sleepiness or drowsiness in the following situations. Rating scale: 1=never sleepy, 2=occasionally sleepy, 3=sleepy about half the time in this situation, 4=get sleepy most of the time, 5=definitely fall asleep or nod off majority if not all the time.

Do you experience any of the following things?

Sleep attacks during the day? (You suddenly get real sleepy & it's hard to get rid of the sleepy spell until it passes)

Some of your muscles suddenly feel weak or go limp when you laugh, get excited, are surprised, or get mad?

Have vivid dreams when you first go to sleep or during short naps?

Feel sleepy or fatigue during the day despite getting enough sleep at night?

Feel paralized or unable to move either upon falling asleep or waking up?

Thoughts race through your mind as you drift off to sleep?

I either noticed or have been told my body parts jerk at night?

I snore or have been accused of snoring at night?

My legs feel uncomfortable at night so I have to move them a lot?

Worry about problems sleeping?

Medical Conditions

Please check the conditions listed below which you have been diagnosed by a physician or specialist (ex. rheumatologist). Also if you feel you may have any of these conditions please check the appropriate box.

Chronic Fatigue Syndrome

Fibromyalgia

Irritable Bowel Syndrome

Migraine Headaches

Hypothyroidism

Lupus (SLE)

Multiple Chemical Sensitivity

Sleep Disorder*

Temporomanidibular Joint Disorder (TMJ or TMD)

Myofascial Pain Syndrome

Depression

Memory loss, dementia or other cognitive deteriation

*
Includes insomnia, sleep apnea, narcolepsy, excessive daytime sleepiness, alpha delta abnormality, restless leg syndrome, periodic limb movement.

Are you currently taking any medication on a regular basis that causes drowsiness or has drowsiness
listed as a side effect?

Do you have any other medical condition which causes fatigue or drowsiness?

If yes, please list these conditions: