Sleep Study Morning Questionnaire
Please complete all sections as accurately as possible
Submission Date
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Day
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Month
Year
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First Name
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Middle Name
Last Name
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Date of Birth
*
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Day
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Month
Year
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What time did you turn the lights out and attempt sleep?
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Hour
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10
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30
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50
Minutes
AM
PM
AM/PM Option
What time did you wake up and end the study?
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Hour
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10
20
30
40
50
Minutes
AM
PM
AM/PM Option
After getting into bed, did you engage in any other activity prior to attempting sleep? Select more than one option if applicable.
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No
Read
Watched TV
Used my mobile phone
Other
How long did you engage in the above activities for, before attempting sleep?
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Less than 5 minutes
5 to 15 minutes
15 to 30 minutes
30 to 60 minutes
1 to 2 hours
More than 2 hours
Once you started attempting sleep, how long do you believe you took to fall asleep?
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Less than 5 minutes
5 to 15 minutes
15 to 30 minutes
30 to 60 minutes
1 to 2 hours
More than 2 hours
How long did it take you to fall asleep last night compared with a normal night?
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Much longer
Slightly longer
About the same
Slightly shorter
Much shorter
How many times do you believe you woke up during the night?
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0
1-2
2-5
5-10
10-20
20+
Please describe anything that disturbed or affected your sleep
Overall, how did you sleep last night when compared to a normal nights sleep?
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Much better
Slightly better
About the same
Slightly worse
Much worse
Please describe how you felt when you woke this morning (i.e. alert, refreshed, tired etc.).
*
Please rate our service out of 5 stars and leave any feedback you may have in the additional information box below
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Additional Information
Please add any additional information leading up to your sleep study that you believe could be relevant
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