Volunteer Sleep Coaching Questionnaire

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.

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Name
Address
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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):
MY MAIN SLEEP COMPAINT IS (check all that apply):
Please check any of the following statements that are true for you:
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:
IF YOU HAVE A BED PARTNER, please have them confirm which of the following have they observed you doing?