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Online Sleep Questionnaire

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Please complete the following questionnaire, answering questions to the best of your ability. There is space at the end for you to clarify any answers or add information.

Personal Information

First Name * Last Name *

Date July 20, 2024

Date of Birth *

Birth Sex * Gender Identity *

Height * Weight *

Referring Doctor *

Why were you referred to the Sleep Health Institute?

Describe why you have been referred to The Sleep Health Institute *

Click the radio button next to the main reason for your referral (one choice only). *
Click the check boxes for any other ongoing sleep problems (multiple choices ok).
bruxism (grinding teeth) circadian rhythm disorder delayed sleep phase syndrome
excessive daytime sleepiness insomnia narcolepsy
obstructive sleep apnea periodic limb movements of sleep REM sleep behavioral disorder
restless leg syndrome shift work sleep disorder sleeptalking
sleepwalking Other

Previous Evaluation

Have you ever been evaluated for a sleep problem? * Yes No

Sleep Questions

How long have you had your sleep problem? *

How much difficulty do you have falling asleep?: * 0 = no problem, 5 = great difficulty
0 1 2 3 4 5

What time do you get in bed for the night on:
Weekdays? * Weekends? *

What time do you turn out the lights with the intention of going to sleep on: *
Weekdays Weekends

What clock time are you typically asleep by on: *
Weekdays Weekends

How many hours of sleep do you get on an average night? *

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