Sleeping Habits Survey
Name (optional)
First Name
Last Name
Age
What time do you go to bed on a school night?
Before 9 pm
9 pm - 10 pm
10 pm - 11 pm
11 pm -midnight
Later than midnight
I do not have a regular bed time
Is there a specific reason for going bed at that time?
Yes, my parents set that time
Yes, I have set that time
Yes, I finish my homework/study at that time
Yes, because I need to get up early for school
Yes, because I get up early in the morning to do exercise
Yes, otherwise I feel sleepy the other day
Yes, the TV show I watch regularly ends at that time
Yes, I am not allowed to use the internet later than that time
No, I go to bed because I feel sleepy
Other
How many times do you past your regular sleeping time?
Never
Once in a week
2-3 times in a week
4 or more times in a week
I do not have a regular bed time
Do you regularly miss school/late for school due to feeling sleepy or not waking up on time?
Never
Once in a week
2-3 times in a week
4 or more times in a week
I never be at school on time
How long does it take you to sleep after going to bed?
I fall asleep immediately
It takes 10 min to fall asleep
It takes 10-20 mins to fall asleep
It takes 20-30 mins to fall asleep
It takes more than 30 mins to fall asleep
How do you usually wake up in the morning?
With an alarm
Noises in the house
Noises from outside of the house
My parents wake me up
My pet wakes me up
I have to use the bathroom
It is a habit
Other
Is it's up to you, what time would be ideal time for school to start?
Earlier than 7 am
7 am
8 am
9 am
10 am
11 am
Later than 11 am
Do you have a chronic illness/disease or any health problem?
Yes
No
Please give details
Please state your agreement with the following statements
Rows
Strongly disagree
Disagree
Neutral
Agree
Strongly Agree
I have sleeping difficulties
1
2
3
4
5
I usually wake up in the middle of the night and cannot go back to sleep
6
7
8
9
10
I usually wake up in the middle of the night but can go back to sleep
11
12
13
14
15
It is very difficult for me to wake up in the morning
16
17
18
19
20
I feel very unrested when I wake up
21
22
23
24
25
Please state your agreement with the following statements that possibly cause struggling sleeping
Rows
Strongly disagree
Disagree
Neutral
Agree
Strongly Agree
Uncompleted homework
26
27
28
29
30
Stress of assignments
31
32
33
34
35
Stress of tests
36
37
38
39
40
Stress of failing at school
41
42
43
44
45
Relationship problems
46
47
48
49
50
Watching too much TV before sleep
51
52
53
54
55
Excessive spending time on social media in bed
56
57
58
59
60
Lack of physical activity
61
62
63
64
65
Noises in the house
66
67
68
69
70
Noises from outside of the house
71
72
73
74
75
Room temperature
76
77
78
79
80
Bad dreams
81
82
83
84
85
Breathing problems
86
87
88
89
90
Please share any comments
Submit
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