Sleep Hygiene and Related Disorders

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* 1. Please take a few moments to do our Sleep Survey. When your questionnaire is complete, a Health Renewal doctor will evaluate your answers. Please tick the box below if you agree that a Health Renewal doctor can call you to discuss your score?

I agree

I do not agree

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* 2. What is your Name and Surname?

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* 3. Which Renewal Institute branch is your home branch?

Brooklyn

Bedfordview

Claremont

Cape Quarter

Constantia

Durban

Fourways

Hillcrest

Irene

Illovo

Morningside

Parkhurst

Stellenbosch

Umhlanga

Willowbridge

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* 4. Please select your Gender?

Male

Female

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* 5. What is your Age?

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* 6. How many hours of uninterrupted sleep do you get, on average, each night?

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* 7. Do you use electronic devices right before going to bed?

Yes

Sometimes

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* 8. Do you have difficulty falling or staying asleep?

Yes

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* 9. Do you wake up tired in the morning?

Yes

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* 10. Do you sleep on your stomach or sides rather than your back?

Yes

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* 11. Are you abnormally tired during the day?

Yes

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* 12. Have you been diagnosed with chronic fatigue?

Yes

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* 13. The Fatigue Severity Scale (FSS) evaluates the impact of fatigue on you and requires you to rate your level of fatigue.

Read each statement and select a number from 1 to 7, based on how accurately it reflects your condition during the past month and the extent to which you agree or disagree that the statement applies to you.

1 = indicates strong disagreement with the statement
7 = indicates strong agreement with the statement

	1 = Strong disagreement	2	3	4	5	6	7 = Strong agreement
My Motivation is lower when I am fatigued	My Motivation is lower when I am fatigued 1 = Strong disagreement	My Motivation is lower when I am fatigued 2	My Motivation is lower when I am fatigued 3	My Motivation is lower when I am fatigued 4	My Motivation is lower when I am fatigued 5	My Motivation is lower when I am fatigued 6	My Motivation is lower when I am fatigued 7 = Strong agreement
Exercise brings on my fatigue	Exercise brings on my fatigue 1 = Strong disagreement	Exercise brings on my fatigue 2	Exercise brings on my fatigue 3	Exercise brings on my fatigue 4	Exercise brings on my fatigue 5	Exercise brings on my fatigue 6	Exercise brings on my fatigue 7 = Strong agreement
I am easily fatigued	I am easily fatigued 1 = Strong disagreement	I am easily fatigued 2	I am easily fatigued 3	I am easily fatigued 4	I am easily fatigued 5	I am easily fatigued 6	I am easily fatigued 7 = Strong agreement
Fatigue interferes with my physical functioning	Fatigue interferes with my physical functioning 1 = Strong disagreement	Fatigue interferes with my physical functioning 2	Fatigue interferes with my physical functioning 3	Fatigue interferes with my physical functioning 4	Fatigue interferes with my physical functioning 5	Fatigue interferes with my physical functioning 6	Fatigue interferes with my physical functioning 7 = Strong agreement
Fatigue causes frequent problems for me	Fatigue causes frequent problems for me 1 = Strong disagreement	Fatigue causes frequent problems for me 2	Fatigue causes frequent problems for me 3	Fatigue causes frequent problems for me 4	Fatigue causes frequent problems for me 5	Fatigue causes frequent problems for me 6	Fatigue causes frequent problems for me 7 = Strong agreement
My fatigue prevents sustained physical functioning	My fatigue prevents sustained physical functioning 1 = Strong disagreement	My fatigue prevents sustained physical functioning 2	My fatigue prevents sustained physical functioning 3	My fatigue prevents sustained physical functioning 4	My fatigue prevents sustained physical functioning 5	My fatigue prevents sustained physical functioning 6	My fatigue prevents sustained physical functioning 7 = Strong agreement
Fatigue interferes with carrying out certain duties and responsibilities	Fatigue interferes with carrying out certain duties and responsibilities 1 = Strong disagreement	Fatigue interferes with carrying out certain duties and responsibilities 2	Fatigue interferes with carrying out certain duties and responsibilities 3	Fatigue interferes with carrying out certain duties and responsibilities 4	Fatigue interferes with carrying out certain duties and responsibilities 5	Fatigue interferes with carrying out certain duties and responsibilities 6	Fatigue interferes with carrying out certain duties and responsibilities 7 = Strong agreement
Fatigue is among my three most disabling symptoms	Fatigue is among my three most disabling symptoms 1 = Strong disagreement	Fatigue is among my three most disabling symptoms 2	Fatigue is among my three most disabling symptoms 3	Fatigue is among my three most disabling symptoms 4	Fatigue is among my three most disabling symptoms 5	Fatigue is among my three most disabling symptoms 6	Fatigue is among my three most disabling symptoms 7 = Strong agreement
Fatigue interferes with my work, family, or social life.	Fatigue interferes with my work, family, or social life. 1 = Strong disagreement	Fatigue interferes with my work, family, or social life. 2	Fatigue interferes with my work, family, or social life. 3	Fatigue interferes with my work, family, or social life. 4	Fatigue interferes with my work, family, or social life. 5	Fatigue interferes with my work, family, or social life. 6	Fatigue interferes with my work, family, or social life. 7 = Strong agreement

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* 14. Do you get abnormally sleepy during the day?

Yes

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* 15. The Epworth Sleepiness Scale measures your level of sleepiness.

How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? Even if you have not done some of these things recently, how you would normally have been affected.

	No chance of dozing	Slight chance of dozing	Moderate chance of dozing	High chance of dozing
Sitting and reading	Sitting and reading No chance of dozing	Sitting and reading Slight chance of dozing	Sitting and reading Moderate chance of dozing	Sitting and reading High chance of dozing
Watching TV	Watching TV No chance of dozing	Watching TV Slight chance of dozing	Watching TV Moderate chance of dozing	Watching TV High chance of dozing
Sitting inactive in a public place (e.g. a theatre or a meeting)	Sitting inactive in a public place (e.g. a theatre or a meeting) No chance of dozing	Sitting inactive in a public place (e.g. a theatre or a meeting) Slight chance of dozing	Sitting inactive in a public place (e.g. a theatre or a meeting) Moderate chance of dozing	Sitting inactive in a public place (e.g. a theatre or a meeting) High chance of dozing
As a passenger in a car for an hour without a break	As a passenger in a car for an hour without a break No chance of dozing	As a passenger in a car for an hour without a break Slight chance of dozing	As a passenger in a car for an hour without a break Moderate chance of dozing	As a passenger in a car for an hour without a break High chance of dozing
Lying down to rest in the afternoon when circumstances permit	Lying down to rest in the afternoon when circumstances permit No chance of dozing	Lying down to rest in the afternoon when circumstances permit Slight chance of dozing	Lying down to rest in the afternoon when circumstances permit Moderate chance of dozing	Lying down to rest in the afternoon when circumstances permit High chance of dozing
Sitting and talking to someone	Sitting and talking to someone No chance of dozing	Sitting and talking to someone Slight chance of dozing	Sitting and talking to someone Moderate chance of dozing	Sitting and talking to someone High chance of dozing
Sitting quietly after a lunch without alcohol	Sitting quietly after a lunch without alcohol No chance of dozing	Sitting quietly after a lunch without alcohol Slight chance of dozing	Sitting quietly after a lunch without alcohol Moderate chance of dozing	Sitting quietly after a lunch without alcohol High chance of dozing
In a car, while stopped for a few minutes in traffic	In a car, while stopped for a few minutes in traffic No chance of dozing	In a car, while stopped for a few minutes in traffic Slight chance of dozing	In a car, while stopped for a few minutes in traffic Moderate chance of dozing	In a car, while stopped for a few minutes in traffic High chance of dozing

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* 16. What is the status of your blood pressure?

High

Low

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* 17. Do you have Diabetes/Blood sugar problems?

Yes

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* 18. Do you snore?

Yes

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* 19. Are you gaining weight or finding it very hard to lose weight?

Yes

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* 20. Do you have a family history of Obstructive Sleep Apnea (OSA)?

Yes

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* 21. Do you have a family history of Upper Repository Airways Syndrome (UARS)?

Yes

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* 22. Do you have reflux or heartburn?

Yes

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* 23. Do you feel like you constantly have to clear your throat?

Yes

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* 24. Does it feel like there is a lump in your throat?

Yes

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* 25. Do you have any difficulty swallowing?

Yes

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* 26. Do you suffer from a hoarse voice periodically?

Yes

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* 27. Do you have a niggly ongoing cough?

Yes

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* 28. Do you have asthma?

Yes

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* 29. Do you suffer from chronic sinusitis?

Yes

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* 30. Do you have a post-nasal drip?

Yes

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* 31. Are you very sensitive to pain?

Yes

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* 32. Do you suffer from chronic unexplained pain?

Yes

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* 33. Do you have low libido or erectile dysfunction?

Yes

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* 34. Do you suffer from depression?

Yes

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* 35. Do you suffer from anxiety?

Yes

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* 36. Do you have difficulty concentrating or previously diagnosed with ADHD?

Yes

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* 37. Do you suffer from restless legs?

Yes

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* 38. Do you have cold hands or feet?

Yes

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* 39. Do you feel dizzy or light-headed when you stand up quickly or bend down?

Yes

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* 40. Do you suffer from migraines and/or tension headaches?

Yes

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* 41. Do you have IBS symptoms? (i.e. bloating, cramping, loose stool, constipation, poor digestion, nausea)?

Yes

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* 42. Have you been diagnosed with Fibromyalgia?

Yes

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* 43. Do you have an under-active thyroid?

Yes

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* 44. Would you like a Renewal Institute staff member to contact you to discuss the survey and schedule an appointment?

Yes

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* 1. Please take a few moments to do our Sleep Survey. When your questionnaire is complete, a Health Renewal doctor will evaluate your answers. Please tick the box below if you agree that a Health Renewal doctor can call you to discuss your score?

Question Title

* 2. What is your Name and Surname?

Question Title

* 3. Which Renewal Institute branch is your home branch?

Question Title

* 4. Please select your Gender?

Question Title

* 5. What is your Age?

Question Title

* 6. How many hours of uninterrupted sleep do you get, on average, each night?

Question Title

* 7. Do you use electronic devices right before going to bed?

Question Title

* 8. Do you have difficulty falling or staying asleep?

Question Title

* 9. Do you wake up tired in the morning?

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* 10. Do you sleep on your stomach or sides rather than your back?

Question Title

* 11. Are you abnormally tired during the day?

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* 12. Have you been diagnosed with chronic fatigue?

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* 14. Do you get abnormally sleepy during the day?

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* 15. The Epworth Sleepiness Scale measures your level of sleepiness. How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? Even if you have not done some of these things recently, how you would normally have been affected.

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* 16. What is the status of your blood pressure?

Question Title

* 17. Do you have Diabetes/Blood sugar problems?

Question Title

* 18. Do you snore?

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* 19. Are you gaining weight or finding it very hard to lose weight?

Question Title

* 20. Do you have a family history of Obstructive Sleep Apnea (OSA)?

Question Title

* 21. Do you have a family history of Upper Repository Airways Syndrome (UARS)?

Question Title

* 22. Do you have reflux or heartburn?

Question Title

* 23. Do you feel like you constantly have to clear your throat?

Question Title

* 24. Does it feel like there is a lump in your throat?

Question Title

* 25. Do you have any difficulty swallowing?

Question Title

* 26. Do you suffer from a hoarse voice periodically?

Question Title

* 27. Do you have a niggly ongoing cough?

Question Title

* 28. Do you have asthma?

Question Title

* 29. Do you suffer from chronic sinusitis?

Question Title

* 30. Do you have a post-nasal drip?

Question Title

* 31. Are you very sensitive to pain?

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* 32. Do you suffer from chronic unexplained pain?

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* 33. Do you have low libido or erectile dysfunction?

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* 34. Do you suffer from depression?

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* 35. Do you suffer from anxiety?

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* 36. Do you have difficulty concentrating or previously diagnosed with ADHD?

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* 37. Do you suffer from restless legs?

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* 38. Do you have cold hands or feet?

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* 39. Do you feel dizzy or light-headed when you stand up quickly or bend down?

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* 40. Do you suffer from migraines and/or tension headaches?

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* 15. The Epworth Sleepiness Scale measures your level of sleepiness.

How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? Even if you have not done some of these things recently, how you would normally have been affected.