Pineal Gland Health Assessment Form
Complete this assessment to help evaluate factors that may influence pineal gland health and function.
How would you rate your overall sleep quality in the past month?
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1
2
3
4
5
How many hours of sleep do you typically get per night?
*
Less than 5 hours
5–6 hours
6–7 hours
7–8 hours
More than 8 hours
Do you have difficulty falling asleep or staying asleep?
*
Never
Rarely
Sometimes
Often
Always
How frequently do you use electronic devices (phone, tablet, computer) within one hour before bedtime?
*
Never
Rarely
Sometimes
Often
Every night
Which of the following symptoms have you experienced in the past month? (Select all that apply)
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Difficulty waking up
Daytime fatigue
Mood changes
Frequent headaches
Changes in vision
None of the above
Other
How often do you get exposure to natural sunlight during the day?
*
Rarely
Occasionally
Most days
Every day
Do you regularly consume caffeine (coffee, tea, energy drinks) in the afternoon or evening?
*
Never
Rarely
Sometimes
Often
Every day
Do you take any supplements or medications that may affect sleep or melatonin production?
*
Yes
No
Not sure
How would you describe your stress levels over the past month?
*
Very low
Low
Moderate
High
Very high
Is there anything else you would like to share about your sleep habits, lifestyle, or well-being?
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