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Tell Us About Your Sleep
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1.
How often do you have trouble sleeping?
(Required.)
Almost every night, dammit
A few nights a week
A few nights a month
Almost never, I snooze like a baby
Other (please specify)
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2.
On average, how much sleep to you get per night?
(Required.)
Three hours or less
Four to five hours
Six to seven hours
Eight hours or more
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3.
Are you sleeping better or worse than you were 10 years ago?
(Required.)
Better
About the same
Worse
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4.
What keeps you from sleeping well? Check all that apply.
(Required.)
Night sweats
Body aches and pains
Noisy environment
Partner's snoring
Sleep apnea
Other medical conditions or illnesses
Bad dreams
Anxiety about my family
Anxiety about money or job
Anxiety about sleep itself
Anxiety about the country and the world
A general sense of dread
Brain won't shut down
PTSD
No problem sleeping
Other (please specify)
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5.
Which of the following best describes your main sleep issue?
(Required.)
I have trouble falling asleep at night
I have trouble staying asleep.
I wake up too early and can't get back to sleep
I wake up several times during the night, making for choppy sleep
I have very light sleep, so I never feel entirely rested
Other (please specify)
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6.
How much does your sleep issue impact the quality of your life?
(Required.)
Hardly at all
Minor annoyance
Frequent problem
Major disturbance
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7.
How do you treat your sleep problems? Check all that apply
(Required.)
Over the counter sleeping medication, such as Unisom
Prescription sleeping medication, such as Ambien
Homeopathic sleep medication, such as melatonin
Anti-anxiety medication
Alcohol
Marijuana
Exercise and/or Yoga
Meditation
Visits to a sleep specialist
Hypnotism
CPAP Machine
Giving up or limiting caffeine
Giving up or limiting alcohol
Other (please specify)
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8.
How do you cope the day after a bad night's sleep? Check two that most apply to you.
(Required.)
Find time for a proper nap
Go through the day grumpy
Hold out hope that the next night's sleep will be better
Drink lots of coffee/caffeine
Fall asleep in meetings or in other inappropriate places
Limit my driving for fear I could nod off
Take some type of medication to help me get through the day, either OTC or prescription
Cry a lot
Cancel activities for that night so I can go to sleep early
Eat lots of chocolate
Cancel any rigorous exercise
Exercise harder
Curse the sleep gods
Other (please specify)
9.
What is your best advice for those dealing with insomnia?
10.
If you've visited a sleep specialist, what did you learn?
11.
How do you think menopause has contributed to your sleep issues?
12.
What questions would you like an expert to answer about sleep and insomnia?
13.
Your name
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14.
Your email address please.
(Required.)
