Sleep Assessment

1

What is your name?

First Name

Last Name

3

What is your gender?This can influence your sleep patterns over your lifetime

Male

Female

Other

Prefer not to say

4

What challenges are you currently experiencing with your sleep?

It takes me too long to fall asleep.

I wake up multiple times during the night.

I rely on drugs, alcohol, or supplements to fall asleep.

I don’t have a specific issue, but I want to enhance my sleep for better performance.

Other

5

How much effort have you put into learning about your sleep?

I’ve done very little; I just know my sleep isn’t working.

I’ve taken a few basic steps but feel unsure about what to do next.

I’ve taken many advanced steps to improve my sleep.

I’m a sleep expert! I have plenty of gadgets, knowledge, and experience, and I’m looking for the next challenge.

6

Do you currently track your sleep?

Yes, I track my sleep.

No, I do not track my sleep.

9

Which of these sleep-promoting habits or routines do you follow at least 80% of the time? (select all that apply)

10

Are you interested in any of the following sleep resources to enhance your sleep?

Yes! Please send me information about your private services and programs.

I’m only interested in free resources, please.

Send me both options.

11

Our premium services do involve a financial commitment. What is your budget for improving your sleep and health?We offer options to suit a variety of budgets

Less than $500

$1000-$4000

$5000+

I have no budget timit

Other

12

What is your email?

example@example.com