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Practitioner Questionnaire
Name
*
First
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Email
1. What time do you usually go to bed at night?
*
A. 9-10pm
B. 10-11pm
C. 11-12am
D. 1am or later
2. How long does it usually take you to fall asleep each night?
*
A. 15 minutes or less
B. 15-30 minutes
C. 30-45 minutes
D. 45 minutes or longer
3. What time do you usually get up in the morning?
*
A. 5-6am
B. 6-7am
C. 7-8am
D. 8am or later
4. How many hours of actual sleep do you get at night?
*
A. 8 hours or more
B. 7 hours
C. 6 hours
D. 5 hours or less
5. How often do you have trouble sleeping because you cannot get to sleep within 30 minutes?
*
A. Not during the past month
B. Less than once per week
C. Once or twice per week
D. Three or more times a week
6. How often do you have trouble sleeping because you wake up in the middle of the night or early morning?
*
A. Not during the past month
B. Less than once per week
C. Once or twice per week
D. Three or more times a week
7. How often do you have trouble sleeping because you have to get up to use the bathroom?
*
A. Not during the past month
B. Less than once per week
C. Once or twice per week
D. Three or more times a week
8. How often do you have trouble sleeping because you cough or snore loudly?
*
A. Not during the past month
B. Less than once per week
C. Once or twice per week
D. Three or more times a week
9. How would you rate your sleep quality overall?
*
A. Very good
B. Fairly good
C. Fairly bad
D. Very bad
10. Have you been experiencing tossing and turning, restless sleep, or light sleeping?
*
A. Not during the past month
B. Less than once a week
C. Once or twice a week
D. Three or more times a week
11. How many times do you wake up during the night?
*
A. 0-1
B. 2-3 times
C. 4-5 times
D. 6 or more times
12. On average, how long do you stay awake?
*
A. Less than 5 minutes
B. 6-15 minutes
C. 16-30 minutes
D. 30+ minutes or don't get back to sleep
13. In the previous 18 months have you experienced any stress?
*
A. None
B. Low
C. Medium
D. High
14. How would you rate your current stress levels?
*
A. None
B. Low
C. Medium
D. High
15. What type of stress are you experiencing?
*
A. None
B. Low
New job
Moved house
Starting a family
New Stress
C. Moderate
Financial pressures
Family concerns
Constant work stress
Ongoing stress
D. High
Grief
Loss of a loved one
Health issue
Chronice stress
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Number A
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Number B
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Number C
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Number D
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Practitioners Email
Email
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