Insomnia Quick Assessment
Note:
Your privacy is important to us. We will never share your e-mail address or other personal information. Please see our privacy statement from the link at the bottom of this page.
Please answer the following questions
1. Enter your first name.
2. Enter your e-mail address.
3. How did you hear about Sleep Elementals?
--Please select--
Internet search
My doctor's office
A family member or friend
Web advertisement
E-mail newsletter
Other advertisement
A link from another website
Other
4. What time do you usually go to bed?
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5. How long does it usually take you to fall asleep?
0 hours
1 hour
2 hours
3 hours
4 hours
5 hours
6 hours
7 hours
8 hours
9 hours
10 hours
11 hours
12 hours
0 minutes
5 minutes
10 minutes
15 minutes
20 minutes
25 minutes
30 minutes
35 minutes
40 minutes
45 minutes
50 minutes
55 minutes
6. How long are you awake during the middle of the night?
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1 hour
2 hours
3 hours
4 hours
5 hours
6 hours
7 hours
8 hours
9 hours
10 hours
11 hours
12 hours
0 minutes
5 minutes
10 minutes
15 minutes
20 minutes
25 minutes
30 minutes
35 minutes
40 minutes
45 minutes
50 minutes
55 minutes
7. What time do you wake up for the last time in the morning?
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AM
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8. What time do you get out of bed to start your day?
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9. How many nights per week do you have trouble sleeping?
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0
1
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7
nights per week
10. How long have you had trouble sleeping?
--Please select--
less than a week
1 to 4 weeks
1 to 3 months
4 to 11 months
1 to 3 years
4 to 10 years
more than 10 years
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