A Better Snooze

Client Demographics

Date

Your Legal Name: First, Last

Mobile Number

Email address

Your Age

Your Occupation

Do you live alone?

Yes No

Current Sleep Baseline (Optional)

If currently using a sleep tracker, enter 5 latest sleep score(s), separated by comma.

Chief Sleep Goals (Check all that apply):

Fall asleep faster

Stay asleep throughout the night

Avoid waking up early

Something else

What time do you typically retire for bed?

What time do you typically wake up? (Note: provide the time you actually wake up, not the time that you get out of bed).

Sleep History & Current Sleep Patterns

How long does it take you to fall asleep on average?

20 minutes or less

20-40 minutes

40 minutes or more

How many times are you aware of waking up each night on average?

1 time per night 2 times per night 3 times per night 4 or more times per night Not applicable

If you wake up 1 or more times per night on average, how long does it typically take you to fall back asleep?

30 mins. or less

30-45 mins.

45-60 mins.

60-90 mins. or more

Do you typically retire and wake up at the same time on weekends, and/or Holidays?

Yes No

How long have you experienced difficulty sleeping?

Several days

Several weeks

Several months

Several years

All of your life

Is there any event which precipitated your sleep troubles, i.e. car accident, etc?

Car accident

Loss of a loved one

Traumatic event

Not applicable

What activities do you typically engage in during the 2 hours before bedtime?

internet browsing or computer work

watching TV

reading

journaling

Other

Do you have any specific bedtime rituals that you consistently honor, i.e. warm bath, warm milk or tea, meditation, reading, etc?

Warm Bath

Warm milk, tea, or other beverage

Meditation

Reading

Other

Not applicable

Behavioral Health & Physiology

Have you ever been diagnosed with any mental health issues, i.e. depression, anxiety, etc?

Yes No

Is there a history of mental illness in the family?

Yes No

On a scale of 1-10, with 10 being the happiest, and 1 being the saddest, which number represents your typical mood?

On a scale of 1-10, with 10 being the most stressed, and 1 being the least stressed, which number represents your average stress level on a daily basis?

You indicated yes to the previous question. List any OTC or prescription medication, illegal drugs, alcohol, or natural supplements.

Nutrition and Lifestyle

Are you on any special diet, i.e. vegan, keto, paleo, etc.?

Vegan

Vegetarian

Paleo

Keto

Pescatarian

Not applicable

Other

What time do you typically consume your last meal of the day?

Before 6 pm After 6 pm, but 3 hours or more before retiring to bed Less than 3 hours before retiring to bed Other

What kind of foods are in your last meal of the day?

carbs

proteins

a balanced meal

other

How many of the following do you consume? Check all that apply:

coffee, 1 or more times per day 4 hours or less before bedtime

soda or other caffeinated beverages 4 hours or less before bedtime

chocolate, 1 or more times per day 4 hours or less before bedtime

alcoholic beverages, 1 or more times per day 4 hours or less before bedtime

cigarettes, 4 hours or less before bedtime

none of the above

Do you exercise?

Yes No

What type of exercise do you do?

What time of day do you typically exercise?

5 or more hours before bed 4 or less hours before bed

Has anyone complained that you drink too much alcohol?

Yes No

Do you often find yourself in heated or tense discussions in the 2 hours leading up to bedtime?

Yes No

What activities do you do to relax/provide self care? Select all that apply.

long walks

meditation

stretching

yoga

painting

reading

other

Sleep Environment

Are there curtains, blinds, or other window coverings in the room where you sleep?

Yes No

What electronics are in the room where you sleep? Check all that apply.

Television

iPad

cellular phone

alarm clock (other than cell phone)

Not applicable

Other than a night light, do you sleep with any lights on in the room?

Yes No

On a scale of 1-10 with 1 being the quietest environment and 10 being the loudest environment, what level of noise is routinely in your sleep environment?

Other

What kinds of intervention(s) have you tried in the past to help remedy your sleep challenges?

Keeping a regular sleep routine

Drinking less caffeine

Drinking less alcohol

Drinking more alcohol

Drinking warm milk or other non-caffeinated beverage

Prescription medication

Soothing white noise

Driving

Other

Is there anything else you'd like us to know that we haven't asked?

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