Please respond to each question or statement by marking one box per row. 

In the past 7 days...

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* 1. Have you used our sleep formula β-Rested?

In the last week...

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* 2. My sleep quality was

In the past 7 days…

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* 3. My sleep was refreshing

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* 4. I had a problem with my sleep

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* 5. I had difficulty falling asleep

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* 6. My sleep was restless

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* 7. I felt like I needed help for my anxiety

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* 8. I felt anxious

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* 9. I tried hard to get to sleep

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* 10. I worried about not being able to fall asleep

In the last week...

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* 11. I was satisfied with my sleep

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* 12. In the past week, how many hours of actual sleep did you get on a typical night?

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* 13. What is your date of birth? 

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* 14. Contact Info

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* 15. Physician's Name

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