Sleep Assessment Form

Sleep Assessment

At Thrive Doctor we give the most personalised and impactful suggestions. This questionnaire assesses your sleep quality and disturbances over the past month and will help highlight specific issues.

Personal Information

Full Name *

Email Address *

Phone Number *

Date of Birth

Sleep Pattern (Past Month)

1. What time have you usually gone to bed at night?
[time* bedtime class:form-control]

2. How long (in minutes) has it usually taken you to fall asleep each night?

3. What time have you usually woken up in the morning?
[time* wakeup class:form-control]

4. How many hours of actual sleep have you been getting per night?

Sleep Disturbances (Past Month)

5. During the past month, how often have you had difficulty sleeping because you…

	Not during past month	Less than once a week	1–2 times a week	3+ times a week
Cannot fall asleep within 30 minutes	A	B	C	D
Wake up in the middle of the night or too early	A	B	C	D
Need to get up to use the bathroom	A	B	C	D
Have difficulty breathing comfortably	A	B	C	D
Cough or snore loudly	A	B	C	D
Feel too cold	A	B	C	D
Feel too hot	A	B	C	D
Experience pain	A	B	C	D
Other reason(s)	A	B	C	D

If other difficulties, please describe:

Sleep Behaviour

7. During the past month, how often have you…

	Not during past month	Less than once a week	1–2 times a week	3+ times a week
Taken medicine to help you sleep	A	B	C	D
Had difficulty staying awake during daily activities	A	B	C	D

Daytime Impact

8. During the past month, how much of a problem has it been to maintain enthusiasm for daily activities?
[radio* q8 use_label_element "No problem at all" "A slight problem" "Somewhat of a problem" "A big problem"]

9. How would you rate your sleep quality overall?
[radio* q9 use_label_element "Very good" "Fairly good" "Fairly poor" "Very poor"]

Bed Partner / Roommate Information

10. Do you have a bed partner or roommate?
[radio* q10 use_label_element "No bed partner or roommate" "Partner/roommate in another room" "Partner in same room but not same bed" "Partner in same bed"]

If you have a bed partner or roommate, how often have they noticed the following?

	Not during past month	Less than once a week	1–2 times a week	3+ times a week
Loud snoring	A	B	C	D
Long pauses between breaths	A	B	C	D
Leg movements or twitching	A	B	C	D
Episodes of confusion during sleep	A	B	C	D
Other restlessness	A	B	C	D

If other, please describe:

Consent

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