This is designed to pinpoint what areas of your life may be interfering with your sleep. Use this questionnaire to identify the causes of your sleep problem. You may want to go into some aspects of this questionnaire in more detail with your health professional.
Name: _____________________________________________________________________
Address: ___________________________________________________________________
Phone: _____________________________________________________________________
Email: ______________________________________________________________________
GP: ________________________________________________________________________
Date: ______________________________________________________________________
Tick the items you would like help with:
___ Getting to sleep
___ Staying asleep
___ Early morning wakening
___ Snoring
___ Unrefreshing sleep
___ Daytime tiredness
___ Shift work
___ Other
History:
How long have you had a sleep problem? _________________________________________
What do you think was the trigger? ______________________________________________
Who else in your family has had a sleep problem? __________________________________
Present situation:
The following questions relate to your sleep pattern over the past 4 weeks. Your answers should indicate the most accurate reply for reply majority of the nights.
What time do you usually go to bed? _____________________________________________
How long does it usually take you to fall asleep? ____________________________________
Are you usually tired at bedtime? _______________________________________________
Do you have frequent awakenings? ______________________________________________
If yes, what times and for how long? _____________________________________________
If you wake up in the night, what do you do? (E.g. get up, have a drink, listen to talkback radio etc.)___________________________________________________________________
What time do you wake up for the day? __________________________________________
Do you wake up feeling refreshed? ______________________________________________
Do you wake up to go to the toilet? ______________________________________________
Do you have trouble staying awake while driving, eating meals, sitting in meetings? _______
Do you have a bed partner or a roommate? _______________________________________
Does this person say that you snore; breath-hold, twitches or jerks legs, or has any other sleep disturbances? __________________________________________________________
When did you last fall asleep easily? _____________________________________________
Do you think you get enough sleep? _____________________________________________
How many hours of sleep do you think you need? __________________________________
Bedtime routine:
How do you usually spend the last half hour before you go to bed? ____________________
Do you bring any work home with you? ___________________________________________
Do you do anything to help yourself fall asleep? (E.g. Bath, music, drink, relaxation techniques, etc.) _____________________________________________________________
Bedroom environment:
Do you have a TV or computer in your room? ______________________________________
Is your bedroom noisy? ___________________________________________________
Do you have curtains? ________________________________________________________
Are you too hot or cold at night? ________________________________________________
Is your bed comfortable? ______________________________________________________
What position do you sleep in? _________________________________________________
Snoring:
Do you snore or hold your breath while sleeping? __________________________________
Shift work:
Are you or have you ever been a shift worker? _____________________________________
If yes, what is your schedule? ___________________________________________________
How long have you been a shift worker? __________________________________________
Physical health:
Mark the following with one of these responses:
‘N’ = never; “O” = often; “F’ = frequently
___ Headaches or migraines
___ Palpitations
___ Digestive problems
___ Allergies
___ Sinus problems
___ Excessive perspiration
___ Dizziness
___ Fatigue
___ Muscle weakness
___ Aches and pains
___ Lowered immune systems causing frequent colds
___ Blood pressure Fluctuations
___ Hot flushes
Do you have any medical conditions? ____________________________________________
If yes, please specify: _________________________________________________________
What medications do you take? _________________________________________________
Lifestyle:
Do you exercise? _____________________________________________________________
If yes, please specify: _________________________________________________________
How many cups of coffee do you drink per day? ____________________________________
How many cups of teas do you drink per day? _____________________________________
How much alcohol do you drink per day? _________________________________________
How many cigarettes do you smoke per day? ______________________________________
Do you take any illicit drugs? ___________________________________________________
If yes, please specify: _______________________________________________________
Previous treatment:
Have you had previous treatment for your sleep problem? ___________________________
If yes, what did you try and how effective was the treatment? ________________________
Body clock type:
Are you most productive in the mornings, afternoon or evenings? _____________________
Psychological factors:
What causes you stress in your life? _____________________________________________
Do you have unresolved issues from your past? ____________________________________
What makes you angry? _______________________________________________________
What do you feel guilty about? _________________________________________________
Are you a worrier? ___________________________________________________________
Are you controlling? __________________________________________________________
Do you get down or depressed? _________________________________________________
Are you a perfectionist? _______________________________________________________
Are you overly critical of self or others? ___________________________________________
Are you ambitious? ___________________________________________________________
Do you find it hard to relax? ____________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Are you aggressive? __________________________________________________________
Are you passive? _____________________________________________________________
Do you get adequate time to yourself? ___________________________________________
Are you a ‘peace maker’? ______________________________________________________
Do you have a good sense of humour? ___________________________________________
Do you seek the respect of others? ______________________________________________
Are you easily hurt? __________________________________________________________
Do you cry easily? ____________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Do you lost your temper easily? _________________________________________________
Do you respond well to pressure? _______________________________________________
Are you competitive? _________________________________________________________
Are you over tidy? ____________________________________________________________
Can you let your hair down a enjoy yourself? ______________________________________
Have you ever had mental health problems? ______________________________________
Life satisfaction:
Instructions: Circle the appropriate number, given that1 represents being totally unhappy and 10 being extremely happy.
Work: 1 2 3 4 5 6 7 8 9 10
Home: 1 2 3 4 5 6 7 8 9 10
Social: 1 2 3 4 5 6 7 8 9 10
Sleep Chart:
Use this one week chart to gain a clear picture of your present sleep situation. It can also be used during treatment so that you can see at a glance if yo are improving and what you are doing that makes a different.
Mark as accurately as you can the times you go to bed and the times you are sleep. If you sleep during the day, indicate as such (i.e. mark the numbers either side of ‘12’ as ‘am’ or ‘pm’).
Date: _______________________
8 9 10 11 12 1 2 3 4 5 6 7 8
Total asleep: ____________________________ awake: _____________________________
Date: _______________________
8 9 10 11 12 1 2 3 4 5 6 7 8
Total asleep: ____________________________ awake: _____________________________
Date: _______________________
8 9 10 11 12 1 2 3 4 5 6 7 8
Total asleep: ____________________________ awake: _____________________________
Date: _______________________
8 9 10 11 12 1 2 3 4 5 6 7 8
Total asleep: ____________________________ awake: _____________________________
Date: _______________________
8 9 10 11 12 1 2 3 4 5 6 7 8
Total asleep: ____________________________ awake: _____________________________
Date: _______________________
8 9 10 11 12 1 2 3 4 5 6 7 8
Total asleep: ____________________________ awake: _____________________________
Date: _______________________
8 9 10 11 12 1 2 3 4 5 6 7 8
Total asleep: ____________________________ awake: _____________________________
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