GENERAL SLEEP HABITS

Email-ID        

Contact No.  

1. How many hours of sleep do you usually get per night?    

2. What time do you usually go to bed on WEEKDAYS?  WEEKENDS? 

3. How long does it take you to fall asleep?   

4. How many times do you typically wake up at night?  

5. What time do you usually awaken in the morning on
    WEEKDAYS?     WEEKENDS?  

6. On average, how long do you stay in bed after waking up in the morning?

7. Do you usually: (check all that apply to you)
    sleep with someone else in your bed
    sleep with someone else in your room
   provide assistance to someone during the night (child, invalid, bed partner,         animal)

8. Is your sleep often disturbed by:
   heat
   light
   cold
   bed partner
   noise
   not being in your usual bed
   Other:                      

9. Are your sleep habits on weekends different from the rest of the week?
    no
    yes - please explain       

10. With whom are you now living?(wife, husband, children, parents, etc. and their ages)                  

11. Do you work split shifts or rotating (variable) shifts?  

      If so, what is your schedule?                                        

12. Do you usually drink coffee or tea within 2 hours before you go to bed?
     yes
     no

13. Do you do physical exercises before you go to bed?
     yes
     no

14. Do you read before falling asleep?
     yes
     no

15. Do you take naps during the afternoon or evening?
     never
     seldom
     frequently - if so, for how long 

16. Do you feel refreshed after a short (10-15 minute) nap?
     yes
     no

17. How do you feel after an average night of sleep?
     usually feel drowsy and/or tired if so, for how long:
1 hour2 hours 3 hours
     most of the time,  I feel good
     consistently, I feel good

18. Do you feel better during:
     morning           afternoon          evening

19. Do you take any kind of medication?
Name                           Amount                       How often                   Reason

20. List your daily consumption of the following:

Coffee	Tea
Chocolate	Alcohol
Other Drugs	Over the counter drugs
Colas	Nicotine

Comments: 

EPWORTH SLEEPINESS SCALE

How tired are you, and how likely are you to doze off at inappropriate times?
Read the following situations and use the scale provided to rate your sleepiness.

0 = would never doze
1 = slight chance of dozing
2 = moderate chance of dozing
3 = high chance of dozing