Sleep (Initial Assessment)

Sleep

Unlock the gateway to peak performance by prioritizing the often underestimated power of sleep. Just as a well-tuned instrument produces the most harmonious melodies, your body and mind flourish when nurtured with rejuvenating sleep. Beyond its tranquil embrace lies a realm of transformation, where every dream-fueled slumber mends, enhances, and ignites your potential. Scientifically proven to enhance cognitive function, mood, and creativity, sleep becomes the secret ingredient that propels you towards greatness.

The following questions relate to your usual sleep habits during the past month only. Your answers should indicate the most accurate reply for most of the days and nights in the past month. Please answer all questions.

In the last month, what time have you typically gone to bed at night?Your usual bedtime: *

Usual bed time

In the last month, how many minutes has it usually taken you to fall asleep each night? *

Number of minutes:

In the last month, how many hours of actual sleep did you typically get at night? (This may differ from the number of hours you spent in bed).Hours of sleep/night: *

Usually getting up time:

Select the most appropriate response for each of the following questions. Be sure to answer all questions.

During the past month, how often have you had trouble sleeping because you ….

a) How often have you struggled to fall asleep within 30 minutes? *

Not during the past month

Less than once a week

Once or twice a week

Three or more times a week

b) How often have you experienced waking up in the middle of the night or early morning? *

Not during the past month

Less than once a week

Once or twice a week

Three or more times a week

How often have you had to get up to use the bathroom during the night? *

Not during the past month

Less than once a week

Once or twice a week

Three or more times a week

d) Have you experienced difficulty breathing comfortably? *

Not during the past month

Less than once a week

Once or twice a week

Three or more times a week

e) Have you coughed or snored loudly during sleep? *

Not during the past month

Less than once a week

Once or twice a week

Three or more times a week

f) Have you had bad dreams? *

Not during the past month

Less than once a week

Once or twice a week

Three or more times a week

g) Have you felt excessively hot? *

Not during the past month

Less than once a week

Once or twice a week

Three or more times a week

h) How often have you experienced pain? *

Not during the past month

Less than once a week

Once or twice a week

Three or more times a week

i) How frequently have you experienced difficulty staying awake while driving, eating meals, or engaging in social activities? *

Not during the past month

Less than once a week

Once or twice a week

Three or more times a week

j) How much of a challenge has it been for you to maintain enough enthusiasm to get things done? *

Not during the past month

Less than once a week

Once or twice a week

Three or more times a week

k) How frequently have you used medication (prescribed or over-the-counter) to aid your sleep? *

Not during the past month

Less than once a week

Once or twice a week

Three or more times a week

l) In the last month, how would you assess your overall sleep quality? *

Very good

Fairly good

Fairly bad

bad

Other reason(s): reasons that made you have difficulty sleeping during last month

Do you have a room-mate (RM) or bed partner (BP)? *

No RM or BP

RM or BP in other room

Partner in room; different bed

Partner in same bed

If you have a room-mate or bed partner, ask him/her how often in the past month you have had ...

(a) loud snoring *

Not during the past month

Less than once a week

twice a week

Three or more times a week

(b) long pauses between breaths while sleeping *

Not during the past month

Less than once a week

twice a week

Three or more times a week

Not during the past month

Less than once a week

twice a week

Three or more times a week

(d) episodes of disorientation or confusion during sleep *

Not during the past month

Less than once a week

twice a week

Three or more times a week

(e) other restlessness while you sleep, please describe *

How likely are you to doze off or fall asleep in the following situations?

Use the following scale to choose the most appropriate number for each situation: 0 = would never doze | 1 = slight chance of dozing | 2 = moderate chance of dozing | 3 = high chance of dozing

Sitting and reading *

Watching TV *

Sitting inactive in a public place (i.e. a theatre or meeting) *

As a passenger in a car for an hour without a break *

Lying down to rest in the afternoon *

Sitting and talking to someone *

Sitting quietly after lunch with no alcohol *

In a car while stopped for a few minutes in traffic *

Now follows some questions about some problems you may or may not have had over the past two weeks. Use a tick to indicate your response.

Difficulty falling asleep *

None

Moderate

Severe

Very Severe

Problem waking up too early *

None

Moderate

Severe

Very Severe

To what extent do you perceive your sleep problem as affecting your daily functioning (e.g., daytime fatigue, work/chores, concentration, memory, mood, etc.)? *

To what extent do you believe your sleeping problem is noticeable to others in terms of your quality of life? *

Lastly, could you please let us know what you're hoping to achieve through your treatment in the Sleep Program? *

Problem waking up too early

Sleep

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