Name *

First Name

Last Name

Today's Date *

MM

DD

YYYY

Phone

(###)

###

####

I had trouble sleeping at night *

Yes

No

I was sleepy all day *

Yes

No

I had trouble staying asleep *

Yes

No

7. During the first 30 minutes after waking up in the morning I felt:

Very Groggy

Somewhat Drowsy

Slightly Drowsy but Awake

Alert

Which statements were true for you during the past two weeks

Check all that applies

I had trouble falling asleep at night.

When I did not sleep, I worried about it the next day.

When I woke up during the night, I had trouble going back to sleep.

I woke up in the morning long before I needed to, these last two weeks.

Some nights, I never got to sleep no matter how hard I tried.

When I tried to go to sleep, my mind raced with many thoughts.

At night when I went to bed I did not feel sleepy.

I slept better in an unfamiliar bedroom, such as a hotel or motel room.

When I tried to fall asleep I become anxious or nervous.

When I tried to fall asleep I worried about whether or not I could sleep.

When I tried to fall asleep I often feel hungry or thirsty.

When I tried to sleep I felt pain.

Pain often woke me up or kept me from going back to sleep.

I had a creeping, crawling sensation in my legs when I laid down to sleep.

When I did sleep, I felt that I slept very well.

I was very light sleeper and I was easily awoken by noises.

My sleep was disturbed because of a bed partner.

Heat or cold disturbed my sleep.

I got up in the night for a snack frequently.

Did you have a preference? *

Yes

No