Q1. Which of these activities do you do in your bedroom?(leave blank if none)

Eat
Watch TV
Play Games

Q2. Do you think about the day’s events while in bed?

Often
Sometimes
Never

Q3. How long do you usually spend awake in bed each night?

0 – 30 minutes
30 – 60 minutes
1 hour – 2 hours
2 hours plus

Q4. How long have you had problems sleeping?

I don’t have any problems sleeping
Days
Weeks
Months
Years

Q5. Do you feel stressed during the day or in bed if you can’t sleep?

Often
Sometimes
Never

Q6. Do you feel depressed or upset during the day or at night?

Often
Sometimes
Never

Q7. For any reason, do you feel scared while in bed?

Often
Sometimes
Never

Q8. Do you ever worry about not being able to get to sleep?

Often
Sometimes
Never

Q9. Do you look at a clock in your bedroom during the night while in bed?

Often
Sometimes
Never

Q10. On a scale of 1 – 5, how comfy would you rate your bed?

1 (very uncomfortable)
2
3
4
5 (very confortable)

Q11. Do you ever get any aches or pains from lying on your bed (that you wouldn’t normally)?

Often
Sometimes
Never

Q12. How much light enters your room at night while you sleep?

None
A little
Quite a bit
Lots

Q13. When you sleep away from home, how well do you sleep?

Better
Worse
Same – no change

Q14. Which of these on an average day might you do 2 – 3 hours before bedtime? (leave blank if none)

Drink alcohol
Smoke
Have a drink containing caffeine (tea, coffee)
Eat sugary foods (such as chocolate)
Heavy exercise
Have a meal

Q15. How best describes your activities just before you go to bed?

Stressful
Energetic
Calming
Mellow

Q16. Do you sometimes go to bed when you’re not yet sleepy?

Often
Sometimes
Never

Q17. On a scale of 1 – 5, how active would you describe yourself?

1 (very unactive)
2
3
4
5 (highly active)

Q18. How regular are the times of your meals on a scale of 1 – 5?

1 (Eat at completely different times every day)
2
3
4
5 (Always eat at the same times every day)

Q19. Do you have the same number of meals each day?

Always
Sometimes
Never

Q20. By how much does the time you wake up vary from day to day?

0 – 15 minutes
15 – 30 minutes
30 minutes to an hour
Over an hour

Q21. Do you sometimes take any unplanned naps during the day at random times?

Often
Sometimes
Never

Q22. Do you take sleep medication regularly?

Often
Sometimes
Never

Q23. By how much does the time you go to bed vary from day to day?

0 – 30 minutes
30 minutes to an hour
1 to 2 hours
Over 2 hours