Adult Sleep Questionnaire Step 1 of 9 11% Name* First Last Are you:MaleFemaleAddress* Address line 1 Town / City Postcode Phone number*Email address* Enter email address Confirm email address Date of birth* DD MM YYYY Age (years)HeightWeightAre you:SingleMarriedLiving with partnerSeparatedDivorcedWidowedDo you have children living at home?YesNoHow many children, and what are their ages?Do you have pets?YesNoWhat pet(s)?Are you currently working?YesNoYour occupationIs your work:Full-timePart-timeApproximate hours of work a day:Do you smoke?YesNoApproximately how many cigarettes do you smoke per day?Do you have any of the following diagnosed medical conditions? High blood pressure Heart disease Cancer Diabetes Stroke Seizures Epilepsy Sleep apnea Lung disease Other What is/are your medical condition(s)?Are you currently taking any regular medication?YesNoPlease provide details of your medication:Are you currently taking any supplements?YesNoPlease provide details of your supplements: Save questionnaire and continue later? The Epworth Sleepiness Scale How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? This refers to your usual way of life in recent times. Even if you have not done some of these things recently, try to work out how they would have affected you. From the situations listed below, 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 dozingSitting and reading0123Watching TV0123Sitting inactive in a public place (e.g. theatre or meeting)0123Passenger in a car for an hour without a break0123Lying down to rest in the afternoon if circumstances permit0123Sitting and talking to someone0123In a car, while stopped for a few minutes in traffic0123 Save questionnaire and continue later? My Main Sleep Complaint Is:I have trouble falling asleep at nightAlwaysOftenOccasionallyI wake during the night and can’t get back to sleepAlwaysOftenOccasionallyI wake very early in the morning and can't get back to sleepAlwaysOftenOccasionallyI am sleepy all dayAlwaysOftenOccasionallyHow long have your sleep problems been an issue?What have you tried already to address your sleep issues? Save questionnaire and continue later? My Usual Sleep Habits Please complete where relevant.1. On weekdays (work days), I usually go to bed around: : HH MM AM PM 2. On weekdays (work days), the earliest time in the last month I have gone to bed is: : HH MM AM PM 3. On weekdays (work days), the latest time in the last month I have gone to bed is: : HH MM AM PM 4. Describe your routine leading up to bedtime:5. From the following two statements, please add a time for the one that applies to you.a) On weekdays, I set an alarm and wake up at: : HH MM AM PM b) On weekdays, I don't set an alarm and generally wake up at: : HH MM AM PM 6. On weekends, I generally wake up at approximately: : HH MM AM PM 7. To feel my best, I should probably go to bed at approximately: : HH MM AM PM And to feel my best, I should ideally get the following amount of sleep:4 hours or less5 hours6 hours7 hours8 hours9 hours10 hours or more8. In the evening, I usually start feeling tired at around: : HH MM AM PM 9. I often have a 'power nap' in the evening:YesNo10. The length of time that I usually take to fall asleep is:11. On weekdays (work days), I generally wake up before/after an alarm:Before the alarmAfter the alarm12. During the first 30 minutes after waking up in the morning, I usually feel:Very groggySomewhat drowsySlightly drowsy, but awakeAlert13. I take naps during the day:SometimesNeverMost daysApproximately how many naps a week?And how many naps at the weekend?14. After taking a nap, I usually feel:RefreshedGroggyStill tired15. The number of times that I usually wake up during the night is:16. The reason I think I wake up is:17. The time(s) during the night that I wake up is/are (best estimate):18. If I wake up during the night, the time it usually takes for me to fall asleep again is:19. The total amount of time I am awake during the night after I first fall asleep is approximately:20. The dozing time I generally spend between waking in the morning and getting out of bed is approximately:Please tick any of the following statements that are true for you: I have a job that involves shift work or night work I frequently travel across times zones I feel that sleep is a waste of time I enjoy sleeping very much I usually sleep with a bed partner My usual sleep position is:On my backOn my sideOn my stomachI don't have a single usual positionI remember dreaming:RarelyAbout once a weekA few times a weekNearly every nightTypically, my dream recall is:Only a vague feeling of having dreamed somethingA sketchy story, image or thoughtA fairly detailed and complex recollection Save questionnaire and continue later? My Sleep Environment Please complete where relevant.1. My room is generally:Completely darkSome lightQuite bright2. My room is generally:Very warmQuite warmCold3. My mattress is:HardSoftAnd for how many years have you had your mattress?4. How many windows are there in your bedroom?5. There are blackout blinds/curtains on the windows:YesNo6. I have an alarm clock by my bed:YesNoAnd is the alarm clock always illuminated?YesNo7. I sleep with an iPad/tablet or smartphone by my bed:YesNoAnd is the iPad/tablet or smartphone set to 'Silent Mode'?YesNo8. I have scented candles, air fresheners or other fragrances in my bedroom:YesNo9. I have a TV in my bedroom:YesNo10. I watch TV before or when I am in bed:YesNo11. I am on my computer before or when I am in bed:YesNo11. I use sleep aids such as white noise, eye shades or ear plugs:YesNoPlease specify which sleep aids you use:Sunlight Exposure1. I first get sunlight exposure in the morning at around: : HH MM AM PM 2. The total number of hours of sunlight exposure I get each day is about:InsomniaPlease tick any of the following statements that are true for you: I have trouble falling asleep at night When I do not sleep, the next day I worry about how I'm feeling When I wake up during the night, I have trouble going back to sleep I wake up in the morning long before I have to Some nights, I never get to sleep When I try to go to sleep, my mind races with many thoughts At night when I go to bed, I do not feel sleepy I often sleep better in an unfamiliar bedroom, such as a hotel room When I can't fall asleep, I become anxious When I try to fall asleep I worry about whether or not I can sleep When I try to fall asleep I often feel hungry or thirsty Pain often wakes me up or keeps me from going back to sleep I have a creeping, crawling sensation in my legs when I lie down to sleep When I do sleep, I feel that I sleep very well I am a very light sleeper; I am easily awakened by noise or light My sleep is disturbed because of my bed partner Heat or cold disturbs my sleep Generally I get up in the middle of the night for a snack I go to the toilet often while I'm trying to get to sleep Save questionnaire and continue later? Daytime SleepinessPlease tick any of the following statements that are true for you: I have sometimes fallen asleep at very inappropriate times, such as while driving, eating, in a meeting, or during a conversation I have sometimes been so sleepy that I became confused or lost track of the topic during a conversation I am frequently so sleepy during the day that my work is poor I have had accidents or near-accidents when driving because I felt so sleepy When I have no plans or appointments the next day, I tend to go to bed later than usual I frequently do not feel sleepy at bedtime and stay up until it is late, and as a consequence I get too little sleep Disturbed SleepPlease tick any of the following statements that are true for you: I have been told that I snore very loudly Sometimes a person cannot sleep in the same room with me because he/she is bothered by my snoring My bed covers are very messy in the morning I am a very restless sleeper I have been told that I kick or poke my bed partner while I am asleep I have hallucinations or dreamlike images when I am not actually asleep, but while falling asleep or waking up I sometimes awaken with a choking sensation I have been told that I stop breathing when I sleep I have fallen out of bed I have been told that I make rolling or rocking movements during sleep I sometimes have felt paralysed or unable to move when waking or falling asleep I wake up suddenly from sleep with an unpleasant feeling of fear, anxiety, tension or unhappiness I wake up from sleep with a feeling of muscle tension or tightness in my arms or chest Sometimes I wake up with a headache I have awakened from sleep once or more having vomited or with heartburn When I wake during the night, I often have to get up and go to the bathroom I sweat a lot when I sleep I feel that the quality of my sleep is unsatisfactory I have been told that my legs twitch or jerk while I am sleeping I toss and turn a lot during the night Parasomnias (e.g. nightmares, night terrors, sleep walking etc)Please tick any of the following statements that are true for you: I have been told that I grind my teeth when I sleep I have been told that I talk in my sleep As an adolescent or child, I have been seen sleepwalking As an adolescent or child, I have been seen sleeptalking I often have frightening dreams My dreams are often very vivid My dreams often wake me As an adult, I have wet my bed (for no rational reason) I have been told that I bang or twist my head at night Save questionnaire and continue later? Stress Management1. Do you feel that you are constantly under pressure, veering from one deadline or crisis to another?NeverRarelySometimesOftenAlways2. Do you regularly work long hours or overtime?NeverRarelySometimesOftenAlways3. Do you do any exercise?YesNoWhat exercise?And how many times per week?1-2 times per week3-4 times per week5-7 times per week4. Do you find it hard to give yourself time to do nothing?YesNo5. Do you often try to do several tasks simultaneously?NeverRarelySometimesOftenAlways6. Do you feel that you have lost or are losing a sense of control in your life?NeverRarelySometimesOftenAlways7. Do you feel that you have the right balance in your life with work, family and socially?YesNo8. Do you get impatient if people hold you up?NeverRarelySometimesOftenAlways9. Do you have a positive attitude/outlook on life?NeverRarelySometimesOftenAlways10. Do you find it difficult to switch off from work in the evening or at the weekend?NeverRarelySometimesOftenAlways11. Do you feel anxious or are you constantly worrying?NeverRarelySometimesOftenAlwaysWhat are the main things you worry about?12. How often have you been to your doctor for colds, flu or infections in the last year?0 times1-2 times3-4 times5-6 times7-10 times13. Do you find it hard to concentrate or remember things?NeverRarelySometimesOftenAlways14. Do you ever feel pain in your chest, does your heart pound, or do you find your hands sweaty?NeverRarelySometimesOftenAlways15. Do you experience headaches or migraines on a regular basis?NeverRarelySometimesOftenAlwaysNutrition1. How many cups/glasses of caffeinated drinks (coffee, tea, cola, energy drinks) do you drink daily?01-23-45-67-102. Do you add sugar to hot drinks?YesNo3. How many glasses of water do you drink daily?01-23-45-67-104. Has your appetite changed in the last few months - are you eating more or eating less?MoreLess5. Do you snack a lot during the day?YesNoWhat do you generally snack on?6. Do you eat meals at regular times throughout the day?YesNo7. Would you consider yourself a healthy eater?YesNo Save questionnaire and continue later? To be completed by bed partner (if applicable)Please tick any of the following statements that you have observed by your partner: Loud snoring Light snoring Twitching of legs or feet during sleep Breathing pauses Grinding teeth Sleep-talking Sleep-walking Sitting up in bed not awake Rocking or banging head Kicking with legs during sleep Getting out of bed while not awake Becoming very rigid and/or shaking How long have you been aware of the sleep behaviours that you ticked above?Describe the behaviours ticked above in more detail. Include a description of the activity, the approximate time during the night when it occurs, frequency during the night, and whether it occurs every night.If you have noticed snoring, do you remember hearing short pauses in the snoring or occasional loud 'snorts'?OutcomesHow committed are you to making changes to your lifestyle to support the sleep challenge you are experiencing?How supportive is your support system – partner etc?What is your goal in terms of sleep? Save questionnaire and continue later? Sleep Consultant Contract & Letter of Agreement As Sleep Consultants, we are dedicated to helping you improve your sleep. This letter is our agreement regarding our services. We agree to the following: Our Services: Following a free preliminary phone conversation to discuss your current sleep situation and options for packages, we will send you an email with a link to the Sleep Questionnaire to complete online, including a daily sleep & food log and this Letter of Agreement for your e-signature. Following submission of the completed questionnaire and logs to us, you can go to our website to book a consultation date. Please allow at least a week after submission of your questionnaire and logs for the consultation date, in order to enable us to process the questionnaire and adequately prepare for our consultation. During the consultation, we will discuss any questions relating to the questionnaire. Based on our evaluation and follow-up questions, we will create a personalised plan for you together, with short and long term goals. After the consultation, a copy of the sleep plan will be sent to you. After the initial consultation, we offer packages with either 2, 4, or 6 follow-up calls. During these follow-ups, we will review how the plan is progressing and discuss possible tweaks to it, if necessary. Any number of additional 30-minute support calls for any of the packages will be charged at £50 each. 1. Your Role: You agree to the following participation in order for the Sleep Plan to be effective: Keep a sleep/wake log during the weeks we are working together. Carry out the steps in the Sleep Plan that we have developed together. Communicate openly with me with any questions or concerns you have about the plan, including any medical, health, or emotional situations that may arise. Discuss your experiences during the plan, so we can make necessary adjustments. Commitment: Coaching is an ongoing relationship between a coach and a client, and changing habits is a process that means achieving positive results may take some time. The opportunity for a successful outcome is significantly increased if you, the client, is prepared to make relevant changes to your lifestyle and daily routine, but understand that coaching is not therapy or counseling. 2. Fees: Our fee structure offers the choice between a Consultation + 2 follow-up calls (Standard Package), Consultation + 4 follow-up calls (Plus Package) or Consultation + 6 follow-up calls (Premier Package). Adult Sleep Standard Package: £200 Review of Sleep Questionnaire and Sleep Logs (submitted prior to consultation). 1½ - 2 hour consultation in consulting rooms or by Skype or Facetime with a camera. Discussion about your sleep challenges, any questions you have and the creation of a detailed, individualised sleep plan tailored to your goals and needs. 2 follow-up calls to discuss how implementation of the plan is going and address any issues. Adult Sleep Plus Package: £250 As above plus: Additional 2 follow-up calls (4 follow-up calls in total) to review how you are progressing with the plan, what improvements you have experienced, and discuss possible next steps. Adult Sleep Premier Package: £300 As above plus: Additional 2 follow-up calls (6 follow-up calls in total) to review progress, address any issues and discuss next action steps. Additional calls will cost £25 for half an hour. Please note: The success of Sleep Coaching will depend on your ability to address and make changes to elements of your life as discussed at the Consultation. The support offered to you during the follow-up calls is usually invaluable and highly recommended, and will make the process more effective, with a greater chance of a successful outcome. 3. Payment Method and Expenses: Fees are to be paid before the consultation by bank transfer. If face-to-face consultation, we will also accept cash. 4. Contacting Us for Follow-Up Sessions: You will book follow-up calls through the website, depending on which package you have booked. 5. Cancellations: If you need to cancel or reschedule your consultation, please notify us 48 hours before your consultation. 6. Insurance: Regrettably, we are unable to accept insurance proceeds. You may, however, submit our invoices to your insurance company, but we cannot guarantee reimbursement for our fees or for any expenses you may incur during the coaching. 7. Confidentiality: We will keep all information we share confidential. You understand there are circumstances that may require us to disclose information (for example, by law or pursuant to a court order). If that occurs, we shall be released from this obligation, but only to the extent of the information we are required to disclose. 8. Our Services Are Not Medical Advice: You understand that we are not medical professionals and will not advise you on medical conditions, or make medical diagnoses. You also understand that your sleep patterns or sleep difficulties may be symptomatic of a condition for which medical intervention or treatment is advisable. If you have any reason to believe that your sleep difficulties may be related to a medical condition, or you have health concerns that may be adversely affected by sleep coaching, it is strongly advised to consult with your doctor before beginning the sleep coaching process. You are solely responsible for discussing any possible medical conditions with your doctor or other health professional. You understand that you assume primary responsibility for your health and, to the extent permitted by law, you will not hold us or our consultancy responsible for any outcomes resulting from complications that are outside of our control. 9. Disclaimer: To the extent permitted by law, The Sleep Works expressly disclaims any liability, loss, damage, or injury caused by information provided to the client. 10. Entire Agreement: This letter reflects the entire understanding between us and may only be changed in writing, signed by both of us. If a court decides any of the terms are unenforceable, we agree that these terms will be severable from the agreement and all other terms of our agreement will remain in effect. 11. Termination: This agreement will terminate automatically upon completion of the services required by this Letter of Agreement. Please acknowledge your agreement and understanding of these terms by signing below. Yours sincerely, Maryanne Taylor Founder and Sleep Consultant, The Sleep Works* REQUIRED I/We have read this letter describing The Sleep Works' services and limits to service and agree that it reflects the discussions we have had and our agreement to the terms of this letter. * REQUIRED: By submitting this form, you consent to your information being stored in The Sleep Works' customer database. Accepted and agreed (your signature)*Use your mouse cursor, or your finger/stylus if you're on a touchscreen device, to write your signature in the field above.Date* DD MM YYYY Client name* First Last EmailThis field is for validation purposes and should be left unchanged. Save questionnaire and continue later?