Sleep and Stress Intake Form
Please answer the following questions about your sleep habits and stress-related routines. This form does not collect sensitive or medical information.
What time do you usually go to bed?
*
Hour Minutes
AM
PM
AM/PM Option
What time do you usually wake up?
*
Hour Minutes
AM
PM
AM/PM Option
On average, how many hours of sleep do you get per night?
*
How would you rate your overall sleep quality?
*
Very good
Good
Fair
Poor
How often do you wake up during the night?
*
Never
Rarely (1-2 times/week)
Sometimes (3-4 times/week)
Often (5+ times/week)
How would you describe your current stress level?
*
Very low
Low
Moderate
High
Very high
Which activities do you use to manage stress? (Select all that apply)
Exercise
Meditation or mindfulness
Talking with friends or family
Listening to music
Reading
Other
How many days per week do you engage in physical activity?
Please Select
0 days
1-2 days
3-4 days
5-6 days
7 days
Do you use electronic devices (phone, TV, computer) within 1 hour before bedtime?
Always
Often
Sometimes
Rarely
Never
How many caffeinated drinks do you consume per day?
Please Select
0
1
2
3
4 or more
Is there anything else you would like to share about your sleep or stress routines?
Submit
Should be Empty: