Sleep Questionnaire Form

This questionnaire is for educational purposes only and is not intended to treat individuals. If you have a medical diagnosis, you are encouraged to seek out treatment from a qualified medical doctor. For more information visit: www.pamkilleen.com.

What is your Name?

What is your email address?

What is your mailing address?

What is your gender?

Male Female

Height

Weight

What is your date of birth?

What is your occupation?

Do you currently work night shifts?

Yes No

Have you worked night shift for at least 2 months in the past?

Yes No

Please list your symptoms:

What is your current MAIN problem/issue with sleep?

Have you been diagnosed with a sleep disorder such as insomnia? If so, please provide details:

During the Night, do you experience any of the following symptoms?

History

How long have you had issues with your sleep?

Is there an identifiable precipitating factor?

Have you had a history of any other sleep disorders?

After you started noticing sleep problems, did you also notice an increase in aches and pains? If so, please clarify.

After you noticed you had trouble sleeping, did you experience any weight gain or weight loss? Please describe.

After you noticed you had trouble sleeping, did you experience any change in appetite? If so, please clarify.

Sleep Quality

How would you rate your sleep quality overall?

Very Good Fairly Good Fairly Bad Very Bad

Presenting problem: What are your most distressing symptoms?

Frequency of Sleep Awakenings

I rarely wake up at night. I wake up at least once a night, but I go back to sleep easily. i wake up more than once a night and have trouble falling back asleep. I often have a restless, light sleep with a few brief awakenings.

If you can fall back asleep after waking up in the middle of the night, how long does it usually take to fall asleep again?

How satisfied/dissatisfied are you with your current sleep pattern?

Please rate the current severity of your sleep disorder:

Mild Moderate Severe

Sleep Hygiene

What happens when you cannot get to sleep?

Do you look at the clock during the night?

Yes No

When you have to wake up a specific time, do you have a harder time going to sleep?

Yes No

When you don't have a commitment the next morning, do you sleep better?

Yes No

Noise and Disturbances

Do you sleep alone?

Yes No, I have a partner No, pets sleep in the bed with me No, a child or children sleep with me

Sleep Disruption Factors

I live on a noisy street My partner, pet or children snore or move a lot during sleep I have noisy neighbours I'm a caregiver

Productivity

After a poor night’s sleep, which of the following problems do you experience the next day?

Daytime fatigue: Tired, washed out, exhausted, sleepy Difficulty functioning: performance impairment at work/chores, difficulty concentrating, memory problems Mood problems: irritable, tense, groggy, nervous, hostile, angry, depressed, anxious, confused, grouchy Physical symptoms: muscle aches/pain, lightheaded, headache, nausea, heartburn, muscle tension None of the above

To what extent do you consider your sleep problem to interfere with your daily functioning (ie: daytime fatigue, ability to function at work, daily chores, concentration, memory, mood, etc.)?

Concentration/Decision Making:

There is no change in my usual capacity to concentrate or make decisions. I occasionally feel indecisive or find that my attention wanders. Most of the time, I struggle to focus my attention or to make decisions. I cannot concentrate well enough to read or cannot make even minor decisions.

Are other friends, co-workers or family members affected by your sleep pattern? Do people around you notice?

Yes No

To what extent do people notice when you're not sleeping well?

Feeling slowed down:

I think, speak, and move at my usual rate of speed. I find that my thinking is slowed down or my voice sounds dull or flat. It takes me several seconds to respond to most questions and I'm sure my thinking is slowed. I am often unable to respond to questions without extreme effort.

Emotional Impact

How worried/distressed are you about your current sleep problem?

Check where applicable ...

I put too much effort into sleeping at night when it should come naturally. I put off going to bed at night for fear of not being able to sleep. I worry about not sleeping if I am in bed at night and cannot sleep. I get anxious about sleeping before I go to bed at night. I worry about the long-term consequences of not sleeping at night.

Dreams

How often do you recall your dreams?

Often Sometimes Rarely Never

Do you experience very vivid dreams while falling asleep or waking up?

Often Sometimes Rarely Never

Substances

Please list any medications, recreational drugs and/or supplements you are currently using or taking:

Do you consume caffeinated beverages? Please list which kinds of caffeinated beverages you consume and how many during the day.

Do you drink alcohol? If so, what kind? How much? How often?

Do you use tobacco products? If so, what kind? How much? How often?

Do you have a history with any other substance? Please comment below.

Circadian Rhythm

How do you feel when you wake up in the morning?

Do you nap? If so, what time? For how long?

Circadian Tendencies

Morning Type Evening Type (a night owl) Neither type

Are you exhausted in the afternoon?

Yes No Sometimes

On weekends (or days off), do you stay up late socializing and then sleep in the next morning?

Yes No Sometimes

Do you use a sleep tracker? If so, which one? Please share any important trends about your sleep.

Diet and Exercise

diet: Please provide examples of what you would eat for a typical breakfast, lunch, dinner and snacks.

Exercise: Please describe your exercise habits. Types? Frequency? Do you exercise indoors or outside?

View of my future

I have an optimistic view of my future. I am occasionally pessimistic about my future, but for the most part I believe things will get better. I'm pretty certain that my immediate future (1-2 months) does not hold much promise of good things for me. I see no hope of anything good happening to me anytime in the future.

What is your sleep goal?

Additional Comments: Is there anything else about your sleep, or anything else, that you think is important and I have not asked you about? Please give details below.