Jet Lag Sleep Assessment
Help us understand how your recent travel has affected your sleep and well-being.
Your Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Age
*
Gender
Male
Female
Non-binary
Prefer not to say
Please provide details about your most recent long-distance trip:
*
How many time zones did you cross during your trip?
*
Direction of travel
*
Eastward
Westward
North-South (minimal time zone change)
How would you rate your sleep quality before and after your trip?
*
Rows
Before Trip
After Trip
Falling asleep easily
1
2
Staying asleep through the night
3
4
Waking up refreshed
5
6
In the past week, how often have you experienced the following symptoms?
*
Rows
Never
Rarely
Sometimes
Often
Always
Daytime sleepiness
7
8
9
10
11
Difficulty concentrating
12
13
14
15
16
Irritability or mood changes
17
18
19
20
21
Headaches
22
23
24
25
26
Digestive issues
27
28
29
30
31
Rate your overall sleep quality since your trip:
*
1
2
3
4
5
Which of the following strategies did you use to manage jet lag? (Select all that apply)
Melatonin supplements
Light exposure therapy
Adjusting sleep schedule before travel
Caffeine management
Hydration
Other
How much has jet lag affected your daily functioning since your trip?
*
Not at all
1
2
3
4
5
6
7
8
9
Severely
10
1 is Not at all, 10 is Severely
If you would like, please add any additional comments about your experience with jet lag and sleep.
Submit Assessment
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