Consciousness and Sleep Assessment
Please complete this form to help us assess your sleep patterns and consciousness levels.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
How would you rate your overall sleep quality in the past week?
*
1
2
3
4
5
How many hours do you typically sleep each night?
*
How often do you experience difficulty falling or staying asleep?
*
Never
Rarely
Sometimes
Often
Always
Do you experience any of the following during sleep? (Select all that apply)
Nightmares
Sleepwalking
Frequent awakenings
Snoring
None of the above
Other
How alert and conscious do you feel during the day?
*
Very drowsy
1
2
3
4
5
6
7
8
9
Fully alert
10
1 is Very drowsy, 10 is Fully alert
Please provide any additional comments or concerns about your sleep or consciousness.
Submit Assessment
Should be Empty: