Comfort, Rest, and Sleep Assessment Form
Please complete this assessment to help us understand your comfort, rest quality, and sleep patterns.
Overall, how comfortable do you feel during your typical day?
*
1
2
3
4
5
How would you rate the overall quality of your rest over the past week?
*
Very Poor
1
2
3
4
Excellent
5
1 is Very Poor, 5 is Excellent
On average, how many hours do you sleep per night?
*
Less than 5 hours
5-6 hours
6-7 hours
7-8 hours
More than 8 hours
How often do you wake up during the night?
*
Never
Rarely (1-2 times a week)
Sometimes (3-4 times a week)
Often (5 or more times a week)
Please indicate how much you agree with the following statements about your sleep over the past week.
*
Rows
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I fall asleep easily
1
2
3
4
5
I stay asleep throughout the night
6
7
8
9
10
I feel rested when I wake up
11
12
13
14
15
My sleep schedule is consistent
16
17
18
19
20
How refreshed do you feel upon waking up?
*
Not at all refreshed
1
2
3
4
Extremely refreshed
5
1 is Not at all refreshed, 5 is Extremely refreshed
Do you experience any discomfort that affects your ability to rest or sleep?
*
No discomfort
Occasional discomfort
Frequent discomfort
How often do you take naps during the day?
*
Never
Occasionally (1-2 times a week)
Frequently (3 or more times a week)
How would you describe your energy level during the day?
*
Very low
Low
Moderate
High
Is there anything else you would like to share about your comfort, rest, or sleep?
Submit Assessment
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