Sleep Risk Assessment How are your sleeping habits impacting your health? Question Title * 1. What time do you go to bed? 8:30PM - 9:30PM 9:30PM - 10:30PM 10:30PM - 11:30PM 11:30PM - 12:00AM 12:00AM + Question Title * 2. Do you wake up with an alarm? Always Usually Rarely Question Title * 3. What position do you sleep in? Back Side Stomach All Over Question Title * 4. Do you wake up in the middle of the night? Always Usually Sometimes Rarely Never Question Title * 5. Do you wake up refreshed and energized? Always Usually Sometimes Rarely Never Question Title * 6. Rate your energy level. 0 100 Clear i We adjusted the number you entered based on the slider’s scale. Question Title * 7. How many cups of coffee do you have? 0-1 2-3 4-5 6+ Question Title * 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 Question Title * 9. What time do you finish dinner? 5:00PM - 6:00PM 6:00PM - 7:00PM 7:00PM - 8:00PM 9:00PM + Question Title * 10. How long does it take you to fall asleep? 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. Question Title * 11. How many hours do you sleep? under 6 6-7 7-8 8-9 10 + Question Title * 12. Do you fall asleep with the tv on? Always Usually Sometimes Rarely Never Question Title * 13. Do you feel tired during the day and feel like you can fall asleep? Always Usually Sometimes Rarely Never Question Title * 14. Do you feel like you would like to hit snooze when you wake up? Always Usually Sometimes Rarely Never Question Title * 15. Rate your energy throughout the day. 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. Question Title * 16. What best describes your current weight? 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. Question Title * 17. What best describes your fitness level? Above average Average Below average Question Title * 18. How many glasses of alcohol do you consume per day on average? 0-1 2-3 3-4 4+ Question Title * 19. What best describes your THC/Marijuana intake? Always Usually Sometimes Rarely Never Question Title * 20. I remember my dreams? Always Usually Sometimes Rarely Never Question Title * 21. Do you tend to wake up in the middle of your dreams? Always Usually Sometimes Rarely Never Question Title * 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 Question Title * 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 Question Title * 24. Address Name Email Address Done
