Let's assess your Sleep and Stress
Sleep is a core recovery mechanism for the body. Inadequate sleep or poor sleep quality can affect many aspects of health over time. Stress is a normal part of life, but the amount of stress you experience and, more importantly, how well you balance stress with recovery can strongly influence its impact on your health. This self-check is designed to help identify strengths and areas for improvement within these lifestyle domains.
DEMOGRAPHICS & CONTACT
Name - Names and other identifying information will be kept private and emails will have names and date of birth redacted for privacy
*
First Name
Last Name
SLEEP QUANTITY & QUALITY
On average how many hours of sleep of you get each night?
Please Select
Less than 6
6-9 Hours
More than 9 hours
Do you have a consistent sleep and wake time (within 1 hour every night/morning)?
Please Select
YES
NO
Do you generally fall asleep without difficulty?
Please Select
YES
NO
How often do you wake and not go immediately back to sleep each night?
Please Select
NEVER - If I wake I go right back to sleep
No More than Once a night
More than Once each night
Do you wake each morning refreshed after sleeping?
Please Select
Everyday
Most days
Occassionally
Never
Rate the quality of your sleep on a scale of 1-10 with 10 being optimal?
Please Select
Less than 5
5, 6, or 7
8 or Higher
When do you stop blue light (Screen time) exposure before bedtime?
Please Select
I get blue light right up until bedtime
I stop blue light exposure 60 minutes prior to bedtime
I stop blue light exposure more than 60 minutes prior to bedtime
Typically my final meal/snack or 'beverage with calories' is _____________.
Please Select
Often just before bedtime
Usually 1-2 hours before bedtime
Usually more than 2 hours before bedtime
Do you use sleep aids (OTC, prescription or other) to help get or stay asleep?
Please Select
NEVER
Occasionally
Often
STRESS, SYMPTOMS & COPING MECHANISMS
What is your overall preception of your stress level on a scale of 1-10, with 10 being maximum?
Please Select
1, 2 or 3
4 or 5
More than 5
5
6
7
8
9
10
How often does your stress level leave you feeling overwhelmed?
Please Select
NEVER
SOMETIMES
OFTEN
Click on all that apply. Do you see physical manifestations of stress?
I do not see any of these
Yes
Click all that apply. Which coping mechanisms do you find helpful and do you use regularly?
Prayer
Meditation
Exercise
Exposure to nature
Alcohol
Eating
Time with friends/loved ones
Escape with TV, Social Media, Reading, etc.
Do you feel your coping mechanisms are healthy?
Please Select
YES
NO
MIXED
Do you have a plan to address your major sources of stress (Work, Family, Financial, Health or Other)?
Please Select
YES
NO
Email - Note we will not share or sell you information. This email will be used to email you your FREE Sleep and Stress Self-Check Report. If you do not provide the email address we cannot send you the report.
*
example@example.com
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