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Welcome
Hi there, please fill out and submit this form to book a free sleep consultation.
20
Questions
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1
Full Name
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First Name
Last Name
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2
Gender
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MALE
FEMALE
NON-BINARY
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3
Age?
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18-24
25-35
36-45
46-55
>55
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4
Email
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FOR CALENDER LINK, CONSULTATION CONFIRMATION & OTHER DETAILS
example@example.com
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5
Mobile/Cell Phone Number
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CONTACT NUMBER
Area Code
Phone Number
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6
How long have you been experiencing sleep difficulties?
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LESS THAN 3 MONTHS
3-12 MONTHS
1-2 YEARS
2-5 YEARS
5-10 YEARS
10-20 YEARS
20+ YEARS
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7
How would you score your current level of motivation to improve your sleep?
*
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0=LOW 10=HIGH
0 (NOT BOTHERED AT ALL)
1-2 (UNINTERESTED)
3-4 (LACKING)
5-6 (NEUTRAL/INTERESTED)
7-8 (DETERMINED)
9-10 (NOTHING ELSE MATTERS)
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8
Do you have any mental or physical health conditions that may be impacting your sleep?
*
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NO
NOT SURE
PREFER NOT SAY
Other
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9
Do you regularly take prescribed medication(s) or substance(s)?
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YES
NO
NOT SURE
PREFER NOT SAY
Other
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10
Have you ever been diagnosed with a sleep disorder?
if yes, please specify condition (if "no" leave blank)
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11
What previous interventions have you tried, in order to improve your sleep?
*
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Tick all those that apply
Prescription medication
Supplements/Herbal remedies (Melatonin, Magnesium etc.)
Aromatherpy
Bed early/late
Limited or restricted caffiene
Meditation/relaxation techniques
No napping
Exercise
Healthy diet/changed diet
Adjustments to bedding and/or bedroom
White noise/ear plugs
Eye mask/black out blinds
Tracked sleep
Sleep study
Sought medical advice (doctor/specialist)
Other
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12
How many hours of total sleep do you get each night on average?
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TOTAL SLEEP
LESS THAN 3 HOURS
3-4 HOURS
4-5 HOURS
5-6 HOURS
6-7 HOURS
7-8 HOURS
8+ HOURS
Other
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13
Symptom regularity
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(Tick as many that apply)
SYMPTOMS OCCUR EVERY NIGHT
THESE SYMPTOMS OCCUR 3 NIGHTS PER WEEK OR MORE
THESE SYMPTOMS OCCUR ONCE OR TWICE PER WEEK
THESE SYMPTOMS OCCUR WHEN AN EXTERNAL CIRCUMSTANCE IS PRESENT/ABSENT (partner, noise, work event)
THESE SYMPTOMS OCCUR ONCE OR TWICE PER MONTH
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14
How long have the symptoms been present?
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*Only select one answer* Symptom duration
THESE SYMPTOMS HAVE LASTED FOR MORE THAN 3 MONTHS
THESE SYMPTOMS HAVE LASTED FOR LESS THAN 3 MONTHS
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15
What is your main sleep complaint?
*
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(Tick as many that apply)
DIFFICULTY FALLING ASLEEP (takes more than 30 minutes to fall asleep at start of night)
DIFFICULTY STAYING ASLEEP (experience awakenings through the night, that take more than 30 minutes to fall back to sleep)
WAKE UP EARLY/BEFORE PLANNED (e.g before alarm)
FEEL UNRESTORED & UNREFRESHED AFTER SLEEP (in day)
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16
Which daytime impairments, following a night of insomnia-affected sleep, do you experience?
*
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(Tick as many that apply)
FATIGUE (FEELINGS OF)
TROUBLE CONCENTRATING, REMEMBERING, PAYING ATTENTION OR RECALLING
IMPAIRED PERFORMANCE IN SOCIAL, WORK, FAMILY OR ACADEMIC SETTINGS
EXCESSIVE DAYTIME SLEEPINESS
HYPERACTIVITY, IMPULSIVITY, AGGRESSION OR OTHER BEHAVIUORAL PROBLEMS
DECREASED ENERGY, MOTIVATION OR MOOD
INCREASED MISTAKES, ERRORS & ACCIDENTS
IRRITABILITY
WORRIED OR CONCERNED ABOUT SLEEP
Other
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17
Other sleep complaints
*
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(Tick as many that apply)
SNORING
SLEEP APNEA (SLEEP DISORDERED BREATHING)
RESTLESS LEGS (OVERWHELMING URGE TO MOVE YOUR LEGS)
INSUFFICENT SLEEP (DISRUPTED SLEEP OR NOT ENOUGH TIME TO SLEEP)
NIGHTMARES, NIGHT TERRORS, SLEEP WALKING/TALKING, OR SIMILAR
NIGHT EATING/SLEEP EATING
NONE OF THE ABOVE
Other
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18
INSOMNIA SEVERITY INDEX
*
This field is required.
Over the last 2 weeks - please rate the current severity of your sleep problem(s) (scroll across for 'very' option)
NONE
MILD
MODERATE
SEVERE
VERY
DIFFICULTY FALLING ASLEEP
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
DIFFICULTY STAYING ASLEEP
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
PROBLEM WAKING UP TOO EARLY
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
CURRENT *DISATISFACTION* WITH SLEEP
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
TO WHAT EXTENT DO YOU CONSIDER YOUR SLEEP PROBLEM TO *INTERFERE* WITH DAILY FUNCTIONING (e.g. fatigue, work, chores, concentration, mood, memory etc.)
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
HOW *NOTICEABLE* TO OTHERS DO YOU THINK YOUR SLEEPING PROBLEM IS IN TERMS OF IMPAIRING THE QUALITY OF YOUR LIFE?
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Row 5, Column 4
HOW *WORRIED* ARE YOU ABOUT YOUR CURRENT SLEEP PROBLEM?
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Row 6, Column 4
DIFFICULTY FALLING ASLEEP
DIFFICULTY STAYING ASLEEP
PROBLEM WAKING UP TOO EARLY
CURRENT *DISATISFACTION* WITH SLEEP
TO WHAT EXTENT DO YOU CONSIDER YOUR SLEEP PROBLEM TO *INTERFERE* WITH DAILY FUNCTIONING (e.g. fatigue, work, chores, concentration, mood, memory etc.)
HOW *NOTICEABLE* TO OTHERS DO YOU THINK YOUR SLEEPING PROBLEM IS IN TERMS OF IMPAIRING THE QUALITY OF YOUR LIFE?
HOW *WORRIED* ARE YOU ABOUT YOUR CURRENT SLEEP PROBLEM?
NONE
Row 0, Column 0
MILD
Row 0, Column 1
MODERATE
Row 0, Column 2
SEVERE
Row 0, Column 3
VERY
Row 0, Column 4
NONE
Row 1, Column 0
MILD
Row 1, Column 1
MODERATE
Row 1, Column 2
SEVERE
Row 1, Column 3
VERY
Row 1, Column 4
NONE
Row 2, Column 0
MILD
Row 2, Column 1
MODERATE
Row 2, Column 2
SEVERE
Row 2, Column 3
VERY
Row 2, Column 4
NONE
Row 3, Column 0
MILD
Row 3, Column 1
MODERATE
Row 3, Column 2
SEVERE
Row 3, Column 3
VERY
Row 3, Column 4
NONE
Row 4, Column 0
MILD
Row 4, Column 1
MODERATE
Row 4, Column 2
SEVERE
Row 4, Column 3
VERY
Row 4, Column 4
NONE
Row 5, Column 0
MILD
Row 5, Column 1
MODERATE
Row 5, Column 2
SEVERE
Row 5, Column 3
VERY
Row 5, Column 4
NONE
Row 6, Column 0
MILD
Row 6, Column 1
MODERATE
Row 6, Column 2
SEVERE
Row 6, Column 3
VERY
Row 6, Column 4
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19
Finally, where did you receive the link for this form?
*
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tick as many that apply
INSTAGRAM
LINKTREE
FACEBOOK
EMAIL
TEXT MSG
WHATS APP
FROM FRIENDS/FAMILY
WEBSITE
GOOGLE PAGE
Other
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20
Thank you for completing this form. Once you press submit this form you will be redirected to a calender site, where you will be invited to book a free sleep consultation call.
I look forward to speaking to you very soon - Dan
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