SLEEP HISTORY QUESTIONNAIRE
Full Name
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First Name
Last Name
Gender
*
Female
Male
E-mail
*
Confirmation Email
Phone Number
*
Format: (000) 000-0000.
How did you hear about us?
Please describe your sleep trouble?
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1. How many nights per week do you usually have difficulty falling asleep?
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0
1
2
3
4
5
6
7
2. On these nights how long does it usually take you to fall asleep after going to bed?
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3. How many nights per week do you wake up in the middle of the night and have difficulty falling back to sleep?
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0
1
2
3
4
5
6
7
3a. On the average, how many times do you wake up on these nights?
3b. How long are you awake during the night?
4. How often do you wake up early in the morning, before your scheduled wake time, and are unable to return to sleep?
5. On nights when you have insomnia, approximately how long do you sleep each night?
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6. On nights when you don't have insomnia, how long do you sleep?
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7. How long would you like to be able to sleep each night?
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8. How long have you had sleep problems?
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9. Are your sleep problem sometimes worse than other times?
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10. Was the onset of your sleep problem related to any specific event?
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11. What do you do to relax prior to bedtime?
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12. What time do you get into bed at night?
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12a. What time do you turn off the lights to go to sleep?
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12b. What time do you get out of bed in the morning?
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13. Do you use your bed for activities other than sleep or sexual activity?
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Yes
No
If yes, please describe:
14. At this time, how much stress would you say there is in your life?
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1
2
3
4
5
6
7
8
9
10
No Stress
High Stress
1 is No Stress, 10 is High Stress
14a. Please list significant stressors in the past 18 months:
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14b. Have you ever been abused, the victim of a crime, or experienced a trauma?
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Yes
No
14c. What resources do you have for emotional support?
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Family
Friends
Religion
Pet
Other
15. Have you received psychological treatment (such as psychotherapy) in the past for depression, anxiety disorder (such as panic disorder) alcohol problems, or other problem?
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Yes
No
If yes, what were you treated for?
16. Are you currently in treatment with any of the following?
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No
Psychiatrist
Psychologist
Social worker
Therapist
Other
17. Have you experienced either depressed mood or loss of interest in pleasure or pleasurable activities for a two week period in the past six months.
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Yes
No
18. How long have you been in therapy?
18a. How often do you go?
18a. What is the focus of treatment?
19. How often is your sleep disturbed by environmental factors such as traffic, neighbors, or family members?
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20. On weekends or your days off, do you sleep more than an hour later than your usual wake up time?
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Yes
No
21. How many times per week do you take naps?
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22. Do you engage in some kind of regular physical exercise?
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Yes
No
If yes, describe the kind, frequency, and time of day:
23. Have you previously, or do you currently, practice any type of relaxation technique?
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Yes
No
If yes, what type:
24. How many cups or glasses of caffeinated beverages (e.g. coffee, tea, or cola) do you drink in a day?
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Rows
0
1
2
3
4
5
6
7
8
9
10
11 or more
Coffee
Tea
Cola
Other
25. How many days a week do you drink caffeinated beverages after 4:00 p.m.?
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0
1
2
3
4
5
6
7
26. How often do you use alcohol to aid sleep?
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27. How often and what amounts of alcohol do you drink?
*
27a. Do you use recreational drugs?
*
28. Does difficulty sleeping ever affect your mood or functioning during the day?
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Yes
No
If yes, describe how your mood or functioning is affected:
Please answer if you answered yes to question 28.
29. Are you sleepy during the day?
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30. Have you recently taken any prescription or over-the-counter medication for sleeping problems?
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Yes
No
30a. If yes, what medication and amount are you taking?
Please answer if you answered yes to question 30.
30b. How many nights a week do you usually take this medication?
1
2
3
4
5
6
7
Please answer if you answered yes to question 30.
30c. How long have you been taking sleeping medication?
Please answer if you answered yes to question 30.
31. Do you snore?
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Yes
No
32. Do you ever wake up in the night and feel unable to breathe?
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Yes
No
33. Do your legs ever jerk repeatedly or feel restless after you go to bed at night?
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Yes
No
34. Are you currently taking any other medication?
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Yes
No
34a. If yes, what medication is it?
Please answer if you answered yes to question 34.
34b. What illness was it prescribed for?
Please answer if you answered yes to question 34.
35. Is there a history of sleeping difficulties in your family?
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Yes
No
36. Have you previously been evaluated or treated for sleeping problems?
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Yes
No
If yes, describe:
Please answer if you answered yes to question 36.
37. Have you tried any self-help remedies for your sleeping problems?
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Yes
No
If yes, describe:
Please answer if you answered yes to question 37.
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