New Client Intake

I’m excited about the opportunity to work with you to enhance your relationship with rest, ensuring you achieve the rejuvenating sleep you deserve. The information you provide here will help us maximize the effectiveness of our initial session. Thank you for taking time to fill share these details.

ADULT SLEEP COACHING QUESTIONNAIRE

This Indepth questionnaire is designed to support a clear understanding of your sleep environment, habits, and concerns. Thank you for completing.

Date

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Birthdate

Height

Weight

Do you have children? If so, how many and how old?

Do you have pets? If so, how many and what type/breed(s)?

Select the option that fits best:

Please list medications you are taking:

Please list any medical conditions (such as sleep apnea, high blood pressure, heart disease, diabetes, stroke, seizures/epilepsy, lung disease, other):

CHANCE OF DOZING while sitting and reading:

CHANCE OF DOZING while watching TV:

CHANCE OF DOZING sitting, inactive in a public place (e.g. a theatre or meeting):

CHANCE OF DOZING as a passenger in a car for an hour without a break:

CHANCE OF DOZING lying down to rest in the afternoon when circumstances permit:

CHANCE OF DOZING sitting and talking to someone:

CHANCE OF DOZING sitting quietly after lunch without alcohol:

CHANCE OF DOZING in a car, while stopped for a few minutes in traffic:

MY MAIN SLEEP COMPAINT IS (check all that apply):

I have trouble sleeping at night

I am sleepy all day

I have unwanted behaviors when I am sleeping

Please describe your sleep concern(s) including nighttime and daytime symptoms:

How long have you had these problems?

Please describe any professional evaluations or treatments for your sleep problem(s), including what was and was not helpful:

Have you tried on your own to improve your sleep and was it helpful?

Have you had a sleep study before? (Where? When?)

On weekdays (workdays), I usually go to bed at (time):

On weekdays (workdays), the earliest time in the last two weeks I have gone to bed is:

On weekdays (workdays), the latest time in the last two weeks I have gone to bed is:

My usual weekend (off days) bedtime is:

On weekdays, I wake up at:

On weekends, I wake up at:

To feel my best, I should go to bed at:

To feel my best, I should get up at:

In the evening, the time I usually start feeling tired is at:

The amount of time that I usually take to fall asleep is:

If you exercise, what is the typical time of day and length of time:

I wake up

After taking a nap, I usually feel:

The number of times I usually wake up during the night is:

The reason I wake up is usually because:

My best estimate of the clock time(s) during the night that I wake up is (are):

If I wake up during the night, the time it usually takes for me to fall asleep again is:

The average amount of time I am awake during the night after I first fall asleep is:

The dozing time I generally spend between awakening in the morning and getting out of bed is:

Please check 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 time zones

I feel that sleep is a waste of time

I enjoy sleeping very much

I usually sleep with a bed partner

I sleep with earplugs and/or eye shades

My usual sleep position is:

I remember dreaming:

My typical dream recall is:

My room temperature at night is:

My bedroom is dark at night:

My mattress is:

How many windows are in your between/sleep environment?

Are windows kept mostly closed or opened?

Is there an alarm clock by your bed?

Do you sleep with a smartphone or ipad/tablet by your bed?

Do you have scented candles, air fresheners or other fragrances in your room?

Is there a TV in your bedroom?

Do you watch TV before or in bed?

Are you on your computer or tablet before or in bed?

Do you use any sleep aids?

Which best describes the noise level in your bedroom while sleeping:

Do you life in a home or apartment/condo/townhome?

Do you share your sleep environment with another/others? If so, describe:

How often do you get direct outdoor sunlight exposure on a daily basis and for how long?

During the first 30 minutes after waking, I usually feel:

DISTURBED SLEEP SYMPTOMS: please check any of these statements that are true for you:

INSOMNIA SYMPTOMS: Please check any of these statements that are true for you:

DAYTIME SLEEPINESS: Please check any of these statements that are true for you:

I sometimes fall asleep at very inappropriate times, such as while driving, eating, or during conversation

I am sometimes so sleepy that I become confused or lose track of the topic during a conversation

I am frequently so sleepy during the day that my work is poor or I cannot complete projects

I have had accidents or near-accidents when driving because I felt so sleepy

When I have no commitments the next day, I frequently go to bed later than my usual bedtime

I frequently do not feel sleepy at bedtime and stay up too late to get enough sleep

Other members of my family have been hyperactive or hyperkinetic as children

Other members of my family have the same sleep problem as I

How often to you feel under pressure or that you're going from one deadline to another?

How often do you work overtime?

How many days per week do you exercise?

Do you find it hard to give yourself time to do nothing?

Do you often multitask, doing 2 to 3 tasks simultaneously?

When you take your holidays do you get sick or start to feel rundown?

Do you feel that you've lost or are losing control in your life and are without balance?

Do you get impatient if people hold you up?

Do you have a positive attitude/outlook on life?

Do you find it difficult to switch off from work on weekends?

How many servings of caffeinated drinks (coffee, tea, energy drinks, cola) do you drink daily?

How often are you feeling tired?

Do you find it hard to get to sleep or stay asleep?

Do you feel anxious or are you worrying?

How often have you been to the doctor for colds, flu's or infections in the past year?

Do you feel pain in your chest, does your heart pound, or do you find your hands sweaty?

How often does your appetite change and you find yourself eating more or eating less

How often do you experience headaches or migraines?

IF YOU HAVE A BED PARTNER, please have them confirm which of the following have they observed you doing?

If a bed partner confirmed any of the above items, how long have they noticed the behavior(s)?

If a bed partner witnessed any of the items listed, what other details can they provide (description of activity, the time during the night it occurs, frequency)?

If a bed partner noticed snoring, do they remember hearing short pauses in the snoring or occasional loud "snorts"?

Thank you for taking the time to complete this questionnaire. I look forward to supporting you and will be reviewing these details prior to our first session together. If you have any additional comments or details you would have wanted to share, please feel free to include here:

New Client Intake

ADULT SLEEP COACHING QUESTIONNAIRE

It’s amazing what you can do in your sleep™