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Sleep Risk Assessment

How are your sleeping habits impacting your health?

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1. What time do you go to bed? (Required.)

8:30PM - 9:30PM

9:30PM - 10:30PM

10:30PM - 11:30PM

11:30PM - 12:00AM

12:00AM +

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2. Do you wake up with an alarm? (Required.)

Always

Usually

Rarely

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3. What position do you sleep in? (Required.)

Back

Side

Stomach

All Over

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4. Do you wake up in the middle of the night? (Required.)

Always

Usually

Sometimes

Rarely

Never

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5. Do you wake up refreshed and energized? (Required.)

Always

Usually

Sometimes

Rarely

Never

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6. Rate your energy level. (Required.)

100

Clear

i We adjusted the number you entered based on the slider’s scale.

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7. How many cups of coffee do you have? (Required.)

0-1

2-3

4-5

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8. Do you need to take medication or a supplement to sleep?

	always	sometimes	rarley	never
Alcohol	Alcohol always	Alcohol sometimes	Alcohol rarley	Alcohol never
THC/gummies	THC/gummies always	THC/gummies sometimes	THC/gummies rarley	THC/gummies never
Melatonin	Melatonin always	Melatonin sometimes	Melatonin rarley	Melatonin never
Sleeping Pills	Sleeping Pills always	Sleeping Pills sometimes	Sleeping Pills rarley	Sleeping Pills never
Other Natural Supplements	Other Natural Supplements always	Other Natural Supplements sometimes	Other Natural Supplements rarley	Other Natural Supplements never

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9. What time do you finish dinner? (Required.)

5:00PM - 6:00PM

6:00PM - 7:00PM

7:00PM - 8:00PM

9:00PM +

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10. How long does it take you to fall asleep? (Required.)

I fall asleep quickly without any problems in under 10 minutes.

It takes me over 10 minutes to fall asleep

It takes me over 20 minutes to fall asleep.

It takes me over 30 minutes to fall asleep.

It takes me over 1 hour to fall asleep.

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11. How many hours do you sleep? (Required.)

under 6

6-7

7-8

8-9

10 +

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12. Do you fall asleep with the tv on? (Required.)

Always

Usually

Sometimes

Rarely

Never

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13. Do you feel tired during the day and feel like you can fall asleep? (Required.)

Always

Usually

Sometimes

Rarely

Never

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14. Do you feel like you would like to hit snooze when you wake up? (Required.)

Always

Usually

Sometimes

Rarely

Never

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15. Rate your energy throughout the day. (Required.)

100% I have no problems with my energy.

75 - 90% I have a small problem with my energy.

50 - 75% I have a problem feeling tired throughout the day.

25 - 50% I feel like I am dragging most days.

I have no energy. I can fall asleep at anytime.

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16. What best describes your current weight? (Required.)

Very satisfied, at my ideal weight.

Satisfied, within 10 pounds of your ideal weight.

Neither satisfied nor dissatisfied, within 15 pounds of your ideal weight.

Dissatisfied, 20 pounds over weight.

Very dissatisfied, 30 plus pounds over weight.

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17. What best describes your fitness level? (Required.)

Above average

Average

Below average

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18. How many glasses of alcohol do you consume per day on average? (Required.)

0-1

2-3

3-4

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19. What best describes your THC/Marijuana intake? (Required.)

Always

Usually

Sometimes

Rarely

Never

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20. I remember my dreams? (Required.)

Always

Usually

Sometimes

Rarely

Never

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21. Do you tend to wake up in the middle of your dreams? (Required.)

Always

Usually

Sometimes

Rarely

Never

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22. If you got better sleep please select all that apply to you.

I would be more productive

I would be less anxious

I would be able to work out

I would have more energy for my family

I would be less irritable

I would travel more

I get great sleep and do not feel like I need it to improve

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23. Please rate your interest in the following.

	Very Interested	Somewhat Interested	A little Interested	Not Interested
Working with a sleep coach to improve your sleep	Working with a sleep coach to improve your sleep Very Interested	Working with a sleep coach to improve your sleep Somewhat Interested	Working with a sleep coach to improve your sleep A little Interested	Working with a sleep coach to improve your sleep Not Interested
Enrolling in an online sleep course and learn how to improve your sleep on your own	Enrolling in an online sleep course and learn how to improve your sleep on your own Very Interested	Enrolling in an online sleep course and learn how to improve your sleep on your own Somewhat Interested	Enrolling in an online sleep course and learn how to improve your sleep on your own A little Interested	Enrolling in an online sleep course and learn how to improve your sleep on your own Not Interested
Join a monthly webinar lead by Dr. Sleep Right about sleep	Join a monthly webinar lead by Dr. Sleep Right about sleep Very Interested	Join a monthly webinar lead by Dr. Sleep Right about sleep Somewhat Interested	Join a monthly webinar lead by Dr. Sleep Right about sleep A little Interested	Join a monthly webinar lead by Dr. Sleep Right about sleep Not Interested

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24. Address (Required.)

Name

Email Address

Sleep Risk Assessment

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* 1. What time do you go to bed? (Required.)

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* 2. Do you wake up with an alarm? (Required.)

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* 3. What position do you sleep in? (Required.)

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* 4. Do you wake up in the middle of the night? (Required.)

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* 5. Do you wake up refreshed and energized? (Required.)

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* 6. Rate your energy level. (Required.)

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* 7. How many cups of coffee do you have? (Required.)

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* 8. Do you need to take medication or a supplement to sleep?

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* 9. What time do you finish dinner? (Required.)

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* 10. How long does it take you to fall asleep? (Required.)

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* 11. How many hours do you sleep? (Required.)

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* 12. Do you fall asleep with the tv on? (Required.)

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* 13. Do you feel tired during the day and feel like you can fall asleep? (Required.)

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* 14. Do you feel like you would like to hit snooze when you wake up? (Required.)

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* 15. Rate your energy throughout the day. (Required.)

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* 16. What best describes your current weight? (Required.)

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* 17. What best describes your fitness level? (Required.)

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* 18. How many glasses of alcohol do you consume per day on average? (Required.)

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* 19. What best describes your THC/Marijuana intake? (Required.)

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* 20. I remember my dreams? (Required.)

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* 21. Do you tend to wake up in the middle of your dreams? (Required.)

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* 22. If you got better sleep please select all that apply to you.

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* 23. Please rate your interest in the following.

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* 24. Address (Required.)

1. What time do you go to bed? (Required.)

2. Do you wake up with an alarm? (Required.)

3. What position do you sleep in? (Required.)

4. Do you wake up in the middle of the night? (Required.)

5. Do you wake up refreshed and energized? (Required.)

6. Rate your energy level. (Required.)

7. How many cups of coffee do you have? (Required.)

8. Do you need to take medication or a supplement to sleep?

9. What time do you finish dinner? (Required.)

10. How long does it take you to fall asleep? (Required.)

11. How many hours do you sleep? (Required.)

12. Do you fall asleep with the tv on? (Required.)

13. Do you feel tired during the day and feel like you can fall asleep? (Required.)

14. Do you feel like you would like to hit snooze when you wake up? (Required.)

15. Rate your energy throughout the day. (Required.)

16. What best describes your current weight? (Required.)

17. What best describes your fitness level? (Required.)

18. How many glasses of alcohol do you consume per day on average? (Required.)

19. What best describes your THC/Marijuana intake? (Required.)

20. I remember my dreams? (Required.)

21. Do you tend to wake up in the middle of your dreams? (Required.)

22. If you got better sleep please select all that apply to you.

23. Please rate your interest in the following.

24. Address (Required.)