Sleep And Stress Assessment
Please complete this assessment to help us understand your sleep patterns and stress levels. Your responses will remain confidential.
Full Name
*
First Name
Last Name
Age
*
Gender
*
Male
Female
Non-binary
Prefer not to say
On average, how many hours do you sleep per night?
*
Please Select
Less than 5 hours
5-6 hours
6-7 hours
7-8 hours
More than 8 hours
How would you rate your overall sleep quality over the past month?
*
1
2
3
4
5
How often do you experience difficulty falling or staying asleep?
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Never
Rarely
Sometimes
Often
Always
In the past two weeks, how often have you felt stressed?
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Never
1
2
3
4
5
6
7
8
9
Always
10
1 is Never, 10 is Always
Please indicate how much the following factors contribute to your stress and sleep issues.
*
Rows
Not at all
A little
Moderately
A lot
Extremely
Work or school pressure
1
2
3
4
5
Family responsibilities
6
7
8
9
10
Health problems
11
12
13
14
15
Financial concerns
16
17
18
19
20
Social relationships
21
22
23
24
25
Which of the following do you use to cope with stress? (Select all that apply)
Exercise
Meditation or relaxation
Talking to friends or family
Hobbies or leisure activities
Professional help (therapy, counseling)
Other
How much do you feel your stress impacts your sleep quality?
*
Not at all
1
2
3
4
5
6
7
8
9
Severely
10
1 is Not at all, 10 is Severely
Is there anything else about your sleep or stress you'd like to share? (Optional)
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