Skip to content
Search for:
Home
About Us
Sustainability Focus
Contact Us
My Dashboard
Search for:
Cart
No products in the cart.
Clear Cart
Sleep Assessment Survey (SAS) Tool
*Please tick your answers clearly
Step
1
of
10
0%
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 name
Clinic Email
(Required)
Patient Name
(Required)
First
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
No
If yes what is it showing?
Average results each night for:
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)
<5
6
7
8
9
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
No
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
No
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. Is your sleep schedule consistent throughout the week, including weekends?
(Required)
Yes
No
11. Have you recently travelled across two or more time zones?
(Required)
Yes
No
If yes, how many time zones and when? If no, skip to question 14
(Required)
12. Do you frequently travel across multiple time zones for work or lifestyle?
Yes
No
If yes, how often?
Rarely
Monthly
Weekly
13. Do you feel that travel affects your sleep pattern or energy levels?
Yes
No
Unsure
If yes, describe briefly
Sleep Environment Habits
14. 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, white noise, 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
None of the above
15. 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
None of the above
16. Do you feel your sleep environment supports good sleep?
(Required)
Yes
No
Sometimes
• If no or sometimes, please explain:
Sleep Continuity
17. Do you sleep all through the night without waking?
(Required)
Yes
Mostly
Sometimes
Never
18. How many nights per week do you wake up in the night?
(Required)
0
1
2
3
4
5
6
7
19. On average, how many times per night do you wake?
(Required)
0
1
2
3
4
5+
20. 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
21. 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?
22. 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
23. On average, how often are you visiting the bathroom during the night?
(Required)
0
1
2
3
4
5+
24. 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
25. Do you toss and turn in your sleep?
(Required)
Yes
No
Sometimes
26. Do you snore, twitch or jerk yourself awake?
(Required)
Yes
No
Sometimes
I don’t know
27. Has anyone ever noticed that you snore loudly, make choking sounds or seem to pause breathing while you sleep?
(Required)
Yes
No
I don't know
28. 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
No
I don't know
If yes, please describe
Waking and Daytime Function
29. Do you feel refreshed on waking?
(Required)
Yes
No
Sometimes
30. Within 30 minutes of waking, how do you feel?
(Required)
Tired
Somewhat refreshed
Refreshed
31. On a scale of 1 to 10 (1 = exhausted, 10 = full of energy), what are your energy levels through the day?
(Required)
1
2
3
4
5
6
7
8
9
10
32. Do you experience daytime fatigue?
(Required)
Never
Sometimes
Mid-morning
Midday
Afternoon
Evening
33. Do you nap during the day?
(Required)
Yes
No
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:
34. Do you ever nod off unintentionally during the day (e.g. while reading, watching TV, or sitting quietly)?
(Required)
Never
Occasionally
Frequently
Almost always
35. Have you ever felt drowsy or fallen asleep while driving?
(Required)
Yes
No
Mental & Emotional Wellbeing
36. Are you experiencing stress?
(Required)
Yes
No
37. On a scale of 1 to 10 (1= low stress, 10= high stress), how would you rate your current stress level?
(Required)
1
2
3
4
5
6
7
8
9
10
Please explain approximately when did it begin?
(Required)
38. Do you think that this stress has been affecting your sleep?
(Required)
Yes
No
39. Have you previously experienced long term stress?
(Required)
Yes
No
If yes - on a scale of 1 to 10 (1= low stress and 10= high stress) how would you rate your previous stress level?
1
2
3
4
5
6
7
8
9
10
Approximately when did it begin?
(Required)
Approximately when did your stress end?
(Required)
40. Was your sleep affected by your stress during this time?
(Required)
Yes
No
41. Do you suffer from day time or night time anxiety?
(Required)
Yes
No
If yes? How long have you had anxiety? What do you experience? What does it stop you doing?
42. Are you currently experiencing feelings of depression?
(Required)
Yes
No
I don't know
If yes, how would you describe the severity? If no, skip to question 44.
Mild
Moderate
Severe
43. Do you feel your depression is affecting your sleep or energy during the day?
Yes
No
Sometimes
If yes, please explain briefly
44. Do you suffer from day time or night time pain, inflammation or discomfort affecting your sleep or daytime activities?
(Required)
Yes
No
If yes? How long have you had pain? What do you experience? What does it stop you doing?
Impact on Daily Life
45. 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)
1
2
3
4
5
6
7
8
9
10
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 ability to socialize?
(Required)
1
2
3
4
5
6
7
8
9
10
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 family time?
(Required)
1
2
3
4
5
6
7
8
9
10
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 experiencing food cravings or making poor food choices?
(Required)
1
2
3
4
5
6
7
8
9
10
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 quality of life?
(Required)
1
2
3
4
5
6
7
8
9
10
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 performance at work?
(Required)
1
2
3
4
5
6
7
8
9
10
51. Do you believe your lack of sleep contributes to any of the following challenges: (Tick all that apply)
(Required)
Memory
Focus
Concentrating on tasks
Mood
Please explain
(Required)
Health History
52. Do you believe your hormones may be impacting your sleep?
(Required)
Yes
No
53. If yes and you are female, is it period cycle related?
(Required)
Yes
No
54. If yes and you are female, is it peri-menopause or menopause related?
Yes
No
55. Do you suffer from nightmares or night terrors?
(Required)
Yes
No
If yes, when did they start, how long for, did anything bring them on, are there any triggers? Please explain.
56. Have you ever been diagnosed with a sleep disorder?
(Required)
Yes
No
If yes, please explain:
57. Do you have restless legs?
(Required)
Yes
No
If yes, please explain what you experience and for how long you have experienced it:
58. Do you experience cramps at night?
(Required)
Yes
No
If yes, please explain what you experience and for how long you have experienced it:
59. Do you have any other sleep related comments? Anything else that you would like to tell us about your sleep?
(Required)
Medications, Supplements & Lifestyle
60. Do you take any medications?
(Required)
Yes
No
Medication
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?
Add
Remove
Do you take any supplements?
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?
Add
Remove
61. Are you allergic to any medications or herbal supplements?
(Required)
Yes
No
If yes, please describe
62. Do you drink alcohol
(Required)
Yes
No
If yes, please explain how many drinks per night and per week and on special occasions:
63. Do you consume recreational drugs or take unprescribed pharmaceuticals?
(Required)
Yes
No
If yes, please explain how many times per day/ per week and on special occasions:
64. Do you have any other health/medical conditions?
(Required)
Yes
No
If yes, please explain:
Search for:
Home
About Us
Sustainability Focus
Contact Us
My Dashboard
Login
