Sleep Assessment Survey (SAS) Tool

*Please tick your answers clearly

Step 1 of 10

Click Here to Download Sleep Assessment Survey

Or Fill out our interactive form below!

Date

MM slash DD slash YYYY

DR Name(Required)

First

Clinic Email(Required)

Clinic name

NHI Number (optional):

Patient Name(Required)

First

Date of Birth

Age(Required)

Gender

Overall Sleep Quality

1. How would you rate your overall sleep?(Required)

Excellent

Very Good

Good

Fair

Poor

2. Are you currently tracking your sleep using device such as actigraphy, smart watch, Oura ring or other sleep tracker?(Required)

Yes

Average results each night for the last month:

Light Sleep:

Deep Sleep:

REM Sleep:

This field is hidden when viewing the form

Section Break

3. How many hours of sleep do you believe you need to feel at your best?(Required)

10+

4. Roughly how long do you spend in bed each night vs how long you’re actually asleep?

Time in bed:(Required)

Estimated time asleep:(Required)

Bedtime Habits

5. Do you find it difficult to fall asleep?(Required)

Yes

If yes, when did this start?(Required)

6. How long does it usually take for you to fall asleep?(Required)

< 15 mins

15-30 mins

30-45 mins

45-60 mins

60+ mins

7. Do you follow a calming routine before bed?(Required)

Yes

If yes, briefly describe?(Required)

8. When do you typically stop using digital devices before sleeping? (Phone, computer, tablet, TV, etc)(Required)

1-5 mins

5-20 mins

20-30 mins

30-60 mins

1 hour +

9. What is your usual bedtime?(Required)

Before 10pm

10-11pm

11-12am

After 12am

I do shift work/other

If you are a shift worker/other, describe your sleep pattern?(Required)

10. Do you usually feel tired before you go to bed?(Required)

Yes

11. Is your sleep schedule consistent throughout the week, including weekends?(Required)

Yes

Have you recently travelled across two or more time zones in the last month?(Required)

Yes

If yes, how many time zones and when?(Required)

13. Do you frequently travel across multiple time zones for work or lifestyle?(Required)

Yes

If yes, how often?

Rarely

Monthly

Weekly

14. Do you feel that travel affects your sleep pattern or energy levels?(Required)

Yes

Unsure

If yes, describe briefly

Sleep Environment Habits

15. Which of the following are present in your sleep environment? (Tick all that apply)(Required)

Room is quiet

Room has background noise (e.g. fan, traffic, TV)

Room is completely dark

Room has some light (e.g., nightlight, electronics, streetlights)

Comfortable mattress and pillows

Uncomfortable bedding or mattress

Bedroom temperature feels just right

Bedroom feels too hot

Bedroom feels too cold

Pets sleep in the bed or bedroom

Children share or enter bed/room at night

Phone or devices kept near the bed

Sleep being disturbed by another person

None of the above

16. Do you use anything to support sleep in your environment? (Tick all that apply)(Required)

Earplugs

Eye mask

White noise machine

Fan or air conditioning

Weighted blanket

Other

None of the above

Other

17. Do you feel your sleep environment supports good sleep?(Required)

Yes

Sometimes

• If no or sometimes, please explain:

Sleep Continuity

18. Do you sleep all through the night without waking?(Required)

Yes

Mostly

Sometimes

Never

19. On average, how many times per night do you wake?(Required)

20. How many nights per week do you wake up in the night?(Required)

21. What is the longest time during the night that you are awake?(Required)

0-5 mins

5-15 mins

15 -30 mins

30 mins - 1 hr

1 -2 hrs

2 - 4+ hrs

22. Why are you waking at night? Tick all that apply.(Required)

No clear reason

Needing the bathroom

Disrupted by noise

Hot flushes/night sweats

Other

If “other”, what are the reasons?

23. If you wake during the night to go to the toilet, ask yourself. Are you waking to go to the toilet or are you going to the toilet because you are awake?(Required)

Wake to use toilet

Awake first, then go

Not Applicable

24. On average, how often are you visiting the bathroom during the night?(Required)

25. How long does it take you to get back to sleep once woken or visited the bathroom?(Required)

< 15 mins

15-30 mins

30-45 mins

45-60 mins

60+ mins

26. Do you toss and turn in your sleep?(Required)

Yes

Sometimes

27. Do you snore, twitch or jerk yourself awake?(Required)

Yes

Sometimes

I don’t know

28. Has anyone ever noticed that you snore loudly, make choking sounds or seem to pause breathing while you sleep?(Required)

Yes

I don't know

29. Has a bed partner, family member or roommate ever observed unusual movements or behaviour during your sleep (e.g. walking, shouting, gasping, kicking)?(Required)

Yes

I don't know

If yes, please describe

Waking and Daytime Function

30. Do you feel refreshed on waking?(Required)

Yes

Sometimes

31. Within 30 minutes of waking, how do you feel?(Required)

Tired

Somewhat refreshed

Refreshed

32. On a scale of 1 to 10 (1 = exhausted, 10 = full of energy), what are your energy levels through the day?(Required)

33. Do you experience daytime fatigue?(Required)

Never

Sometimes

Mid-morning

Midday

Afternoon

Evening

34. Do you nap during the day?(Required)

Yes

Sometimes

This field is hidden when viewing the form

Section Break

If “Yes” or “Sometimes”, what time of the day and for how long?

How long?

Usual nap time:

35. Do you ever nod off unintentionally during the day (e.g. while reading, watching TV, or sitting quietly)?(Required)

Never

Occasionally

Frequently

Almost always

36. Have you ever felt drowsy or fallen asleep while driving?(Required)

Yes

Mental & Emotional Wellbeing

37. Are you experiencing stress?(Required)

Yes

Please explain approximately when did it begin?(Required)

38. On a scale of 1 to 10 (1= low stress, 10= high stress), how would you rate your current stress level?(Required)

39. Do you think that this stress has been affecting your sleep?(Required)

Yes

40. Have you previously experienced long term stress?(Required)

Yes

If yes - on a scale of 1 to 10 (1= low stress and 10= high stress) how would you rate your previous stress level?

Approximately when did it begin?(Required)

Approximately when did your stress end?(Required)

41. Was your sleep affected by your stress during this time?(Required)

Yes

42. Do you suffer from day time or night time anxiety?(Required)

Yes

If yes? How long have you had anxiety? What do you experience? What does it stop you doing?

43. Are you currently experiencing feelings of depression?(Required)

Yes

I don't know

If yes, how would you describe the severity? If no, skip to question 44.

Mild

Moderate

Severe

44. Do you feel your depression is affecting your sleep or energy during the day?

Yes

Sometimes

If yes, please explain briefly

45. Do you suffer from day time or night time pain, inflammation or discomfort affecting your sleep or daytime activities?(Required)

Yes

If yes? How long have you had pain? What do you experience? What does it stop you doing?

Impact on Daily Life

46. On a scale of 1 to 10 (1= not at all, 10= very much) how would you rate the impact your lack of sleep is having on your sex drive?(Required)

47. On a scale of 1 to 10 (1= not at all, 10= very much) how would you rate the impact your lack of sleep is having on your ability to socialize?(Required)

48. On a scale of 1 to 10 (1= not at all, 10= very much) how would you rate the impact your lack of sleep is having on your family time?(Required)

49. On a scale of 1 to 10 (1= not at all, 10= very much) how would you rate the impact your lack of sleep is having on your experiencing food cravings or making poor food choices?(Required)

50. On a scale of 1 to 10 (1= not at all, 10= very much) how would you rate the impact your lack of sleep is having on your quality of life?(Required)

51. On a scale of 1 to 10 (1= not at all, 10= very much) how would you rate the impact your lack of sleep is having on your performance at work?(Required)

52. Do you believe your lack of sleep contributes to any of the following challenges: (Tick all that apply)

Memory

Focus

Concentrating on tasks

Mood

Please explain

Health History

53. Do you believe your hormones may be impacting your sleep?(Required)

Yes

54. If yes and you are female, is it period cycle related?(Required)

Yes

55. If yes and you are female, is it peri-menopause or menopause related?

Yes

56. Do you suffer from nightmares or night terrors?(Required)

Yes

If yes, when did they start, how long for, did anything bring them on, are there any triggers? Please explain.

57. Have you ever been diagnosed with a sleep disorder?(Required)

Yes

If yes, please explain:

58. Do you have restless legs?(Required)

Yes

If yes, please explain what you experience and for how long you have experienced it:

59. Do you experience muscle cramping, such as a sudden painful or tight sensation in any muscles (usually legs)?(Required)

Yes

If yes, please explain what you experience and for how long you have experienced it:

60. Have you experienced any grinding or clenching of your teeth during your sleep, woken with jaw discomfort or tightness, experienced temporal headaches, or been told of abnormal tooth wear?

Yes

If yes, please describe what you experience and how long it has been occurring?

61. Do you have any other sleep related comments? Anything else that you would like to tell us about your sleep?(Required)

Medications, Supplements & Lifestyle

62. Do you take any medications?(Required)

Yes

Medication(Required)

Medication Name

Strength/mg e.g. 75mg

Dosage schedule e.g. 1 -2 tablets Breakfast, Lunch, Dinner – before or after food etc

How long have you been on this medication?

63. Do you take any supplements?(Required)

Yes

Supplements(Required)

Supplement/s name

Strength/mg e.g. 75mg

Dosage schedule e.g. 1 -2 tablets Breakfast, Lunch, Dinner – before or after food etc

How long have you been on this supplement?

64. Are you allergic to any medications or herbal supplements?(Required)

Yes

If yes, please describe

65. What is your current body weight (in kg)?(Required)

66. Are you currently trying to:

Gain weight

Lose weight

Maintain weight

Not sure

67. Do you drink alcohol(Required)

Yes

If yes, please explain how many drinks per night and per week and on special occasions:

68. Do you consume recreational drugs or take unprescribed pharmaceuticals?(Required)

Yes

If yes, please explain how many times per day/ per week and on special occasions:

69. Do you have any other health/medical conditions?(Required)

Yes

If yes, please explain: