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Sleep Assessment
1
Name
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First Name
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2
Email
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3
Type a client
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4
Lifecycle Stage
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5
What is your main sleep complaint?
Select any that apply
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6
How often does this occur?
*
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1-2 days a week.
3-5 days a week.
6-7 days per week.
Other
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7
How long have you had this sleep problem?
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1-4 weeks.
1-3 months.
More than 3 months
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8
Are your sleep time and wake times irregular?
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Yes
No
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9
Do you allocate enough time in bed to get the amount of sleep you need each night?
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Yes
No
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10
Does your lack of sleep problem affect any of your daytime activities?
Select any that apply
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11
Did your sleep problem coincide with a particular event?
*
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ie: relationship breakup, death in family
Yes.
No.
Not sure.
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12
Have you taken any products to help you with sleeping?
*
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Yes
No
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13
What type of products have you used?
Prescription Melatonin.
Other prescription.
Pharmacy medicine (over the counter).
Herbal/vitamin supplement.
Other
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14
How often did you use it?
1-2 days a week.
3-5 days a week.
6-7 days per week.
Other
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15
How long have you been using it?
1-4 weeks.
1-3 months.
3+ months.
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16
Did you get any benefit from the treatment?
Yes
No
Other
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17
Your sleep environment:
Select any that apply
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18
How often do you exercise?
*
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3-5 times per week.
2-3 times a week.
Once a week.
Less than once a week.
Other
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19
How often do you drink alcohol?
*
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Everyday.
Most days.
On weekends.
I don’t drink alcohol.
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20
Do you ever use alcohol to help you sleep?
*
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No
Yes
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21
On average how many coffee’s (or other caffeinated beverages) do you drink per day?
*
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1
2
3
4+
I don’t drink coffee.
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22
Do you use any recreational drugs?
No
Yes
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23
What type do you use?
Stimulants eg: cocaine and amphetamines.
Marijuana.
Other
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24
How would you rate your mood at the moment?
1
2
3
4
5
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25
How is your sleep problem affecting your mood?
Select any that apply
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26
Let’s check if your breathing may be affecting your sleep.
*
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Select any that apply
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27
Other potential causes for your bad sleep?
*
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Select any that apply
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28
How likely are you to doze off when sitting and reading?
*
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Would never doze.
Slight chance of dozing.
Moderate chance of dozing.
High chance of dozing.
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29
How likely are you to doze off when watching TV?
*
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Would never doze.
Slight chance of dozing.
Moderate chance of dozing.
High chance of dozing.
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30
How likely are you to doze off when sitting inactive in a public place (eg a theatre or a meeting)?
*
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Would never doze.
Slight chance of dozing.
Moderate chance of dozing.
High chance of dozing.
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31
How likely are you to doze off as a passenger in a car for an hour without a break?
*
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Would never doze.
Slight chance of dozing.
Moderate chance of dozing.
High chance of dozing.
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32
How likely are you to doze off when lying down to rest in the afternoon when circumstances permit?
*
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Would never doze.
Slight chance of dozing.
Moderate chance of dozing.
High chance of dozing.
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33
How likely are you to doze off when sitting and talking to someone?
*
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Would never doze.
Slight chance of dozing.
Moderate chance of dozing.
High chance of dozing.
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34
How likely are you to doze off when sitting quietly after lunch without alcohol?
*
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Would never doze.
Slight chance of dozing.
Moderate chance of dozing.
High chance of dozing.
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35
How likely are you to doze off when in a car, while stopped for a few minutes in the traffic?
*
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Would never doze.
Slight chance of dozing.
Moderate chance of dozing.
High chance of dozing.
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36
ESS Score
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37
Your Job
*
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Select any that apply
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38
Do you have an existing medical condition?
Select any that apply
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39
Do you take any medication or supplements?
*
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Yes
No
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40
Please list the medication or supplements you take.
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41
Please enter your weight and height.
*
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42
Has your weight changed significantly over the past 12 months?
*
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No
Yes
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43
Have you gained or lost weight?
Please specify how many kgs
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44
Do you have any allergies?
*
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No
Yes
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45
Please list your allergies.
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46
Has an immediate family member had any type of sleep disorder, including sleep apnoea (breathing issues while sleeping), or narcolepsy?
*
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No
Yes
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47
Is there any other information you would like to share with the doctor or specific questions you'd like answered?
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48
I confirm I've answered the above questions honestly and to the best of my knowledge. I understand that the information, advice and treatment provided by Harley are based on these responses.
*
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Yes
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49
What is your preferred method of communication?
*
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Email
SMS
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50
How did you hear about Harley?
*
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Google
Facebook
Instagram
Friend
Other
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