Advanced Alignment SLEEP Short Questionnaire

1

Do you feel it’s impossible to live the life you desire?* This field is required.

YESNO

2

How often does the sleep monster keep you up at night?* This field is required.

Rarely

Few Times Week

Almost every night

3

What impact does a lack of sleep have on you the following day? (Select all that apply.)* This field is required.

less energy

poor work performance

need to take things to “wake up.”

4

Which of these do you struggle with during sleep: (Select all that apply)* This field is required.

Snoring

Headache

Teeth Grinding

Restless Sleep

Waking up to pee

5

What do you feel is the biggest obstacle to getting help?* This field is required.

Money

Significant other not on board

Time

I’m not certain anything will help

6

Would it be crazy to think that your health is worth investing in?* This field is required.

YESNO

7

How much are you realistically willing to invest to feel and function better?* This field is required.

8

If we could help, would you be opposed to learning more?* This field is required.

YESNO

9

Almost there! What is your full name?* This field is required.

10

Date of Birth* This field is required.

11

Great! What is your phone number?* This field is required.

Please enter a valid phone number.

12

What is your e-mail address?* This field is required.

example@example.com

13

Are you available during the daytime or evening for an evaluation?* This field is required.

MorningEvening