Sleep Disorder Patient Feedback
Please share your experience to help us improve your care and understand your sleep disorder symptoms.
Full Name
*
First Name
Last Name
Date of Feedback
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Which type of sleep disorder have you been diagnosed with?
*
Insomnia
Sleep Apnea
Restless Legs Syndrome
Narcolepsy
Parasomnias (e.g., sleepwalking)
Other
Rate your overall sleep quality in the past two weeks.
*
1
2
3
4
5
How often have you experienced the following symptoms in the past two weeks?
*
Rows
Never
Rarely
Sometimes
Often
Always
Difficulty falling asleep
1
2
3
4
5
Waking up during the night
6
7
8
9
10
Waking up too early
11
12
13
14
15
Feeling tired during the day
16
17
18
19
20
Snoring or breathing pauses
21
22
23
24
25
Unusual movements during sleep
26
27
28
29
30
How much does your sleep disorder affect your daily life?
*
Not at all
1
2
3
4
5
6
7
8
9
Extremely
10
1 is Not at all, 10 is Extremely
Are you currently using any treatments or therapies for your sleep disorder?
*
Medication
CPAP/BiPAP machine
Cognitive Behavioral Therapy
Lifestyle changes
None
Other
How effective do you feel your current treatment is?
*
Very effective
Somewhat effective
Not effective
Not applicable
Have you experienced any side effects or complications from your treatment?
*
No
Yes (please describe below)
If yes, please describe any side effects or complications.
Additional comments or suggestions about your sleep disorder experience or treatment.
Submit Feedback
Should be Empty: