Welcome to your FREE Sleep Assessment from EliteSleeping.com
Congratulations on taking the first step towards getting the peaceful, restorative sleep you deserve. Fill in the form, and we will email you our evaluation immediately. Sweet DreamzzZZ!
Email
*
example@example.com
Name
*
First Name
Last Name
1) I have trouble falling asleep
*
Never
Rarely
Occasionally
Most nights/days
Always
2) I have trouble staying asleep
*
Never
Rarely
Occasionally
Most nights/days
Always
3) I take something to help myself sleep (e.g. herbal supplements, OTC drugs, prescription drugs, alcohol, etc)
*
Never
Rarely
Occasionally
Most nights/days
Always
What do you take to help yourself sleep?
4) I have a medical condition that disrupts my sleep
*
Never
Rarely
Occasionally
Most nights/days
Always
What medical condition disrupts your sleep?
5) I try to “catch up on sleep” on weekends or other times*
*
Never
Rarely
Occasionally
Most nights/days
Always
6) I do shift work or otherwise have an irregular sleeping schedule.
*
Never
Rarely
Occasionally
Most nights/days
Always
7) I worry about not getting enough sleep.
*
Never
Rarely
Occasionally
Most nights/days
Always
8) I wake up early in my normal sleep cycle (e.g. 2-3 AM for a regular night-time sleeper).
*
Never
Rarely
Occasionally
Most nights/days
Always
9) If I wake up during my normal sleep cycle, I have trouble going back to sleep.
*
Never
Rarely
Occasionally
Most nights/days
Always
10) I find it hard to wake up or get going after I wake up.
*
Never
Rarely
Occasionally
Most nights/days
Always
11) I wake up with an alarm.
*
Never
Rarely
Occasionally
Most nights/days
Always
12) I hit snooze on the alarm once or more.
*
Never
Rarely
Occasionally
Most nights/days
Always
13) I depend on caffeine or other stimulants to stay awake and alert.
*
Never
Rarely
Occasionally
Most nights/days
Always
14) My sleep is disturbed by factors outside my control (e.g. outside noise, children, etc.)
*
Never
Rarely
Occasionally
Most nights/days
Always
15) I seem to sleep OK, but wake up not feeling refreshed
*
Never
Rarely
Occasionally
Most nights/days
Always
16) I feel fatigued or have low energy when I’m awake
*
Never
Rarely
Occasionally
Most nights/days
Always
17) I recover well from stress or physical demands
*
Never
Rarely
Occasionally
Most nights/days
Always
18) I feel moody, cranky, “down in the dumps”, and/or “blah”
*
Never
Rarely
Occasionally
Most nights/days
Always
19) I struggle to concentrate, learn, and/or remember things
*
Never
Rarely
Occasionally
Most nights/days
Always
20) I normally sleep
*
Fewer than 4 hours / night
4-5 hours / night
5-6 hours / night
6-7 hours / night
7-8 hours / night
8-9 hours / night
9+ hours / night
21) Left to my own devices, without having to accommodate someone else’s schedule, I’d consider myself
*
An early bird
A night owl
A mix, depending on what I want to do
22) I take naps.
*
Never
Rarely
Occasionally
Most nights/days
Always
23) I have a scheduled bedtime, or I plan my bedtime in advance
*
Never
Rarely
Occasionally
Most nights/days
Always
24) At least 30 minutes before bed, I purposely start winding down and preparing for sleep
*
Never
Rarely
Occasionally
Most nights/days
Always
25) I practice meditation or other forms of purposeful relaxation
*
Never
Rarely
Occasionally
Most nights/days
Always
26) I dim the lights or have darkness when it’s night time (or time to sleep)
*
Never
Rarely
Occasionally
Most nights/days
Always
27) I get bright light when I am supposed to be awake and alert (e.g. by going outside during the day or having a light box)
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Never
Rarely
Occasionally
Most nights/days
Always
28) I exercise for at least 20 minutes per day
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Never
Rarely
Occasionally
Most nights/days
Always
29) I eat lightly, or not at all, within 1-2 hours of bedtime
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Never
Rarely
Occasionally
Most nights/days
Always
30) I have a comfortable, calming sleep environment
*
Never
Rarely
Occasionally
Most nights/days
Always
31) I check work email or do other work-related activities within 1-2 hours of bedtime
*
Never
Rarely
Occasionally
Most nights/days
Always
32) I engage in stimulating, energizing, or upsetting activities(e.g. intense workouts, first-person shooter games, etc.) within 1-2 hours of bedtime.
*
Never
Rarely
Occasionally
Most nights/days
Always
33) I shut down all electronics* 30 minutes before bed(e.g. phone, TV, video games, etc.).*Optional: If I use a screen reader (e.g. a Kindle) to read before bed, I dim the screen brightness.
*
Never
Rarely
Occasionally
Most nights/days
Always
34) I do something else to purposely prepare for sleep / bedtime
*
Never
Rarely
Occasionally
Most nights/days
Always
What is it that you do you to purposley prepare for sleep / bedtime?
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