Bettersleep - Sleep Score

1

During the past month, what time have you usually gone to bed at night?

:

PM

2

During the past month, how long (in minutes) has it usually taken you to fall asleep each night?

3

During the past month, what time have you usually gotten up in the morning?

:

AM

4

During the past month, how many hours of actual sleep did you get at night? (This may be different than the number of hours you spent in bed.)

6

During the past month, how often have you taken medicine to help you sleep (prescribed or “over the counter”)?	Not during the past month	Less than once a week	Once or twice a week	Three or more times a week

7

During the past month, how often have you had trouble staying awake while driving, eating meals, or engaging in social activity?	Not during the past month	Less than once a week	Once or twice a week	Three or more times a week

8

During the past month, how much of a problem has it been for you to keep up enough enthusiasm to get things done?	No problem at all	Only a very slight problem	Somewhat of a problem	A very big problem

9

During the past month, how would you rate your sleep quality overall?	Very godd	Fairly good	Fairly bad	Very bad

During the past month, how often have you had trouble sleeping because you…	Not during the past month	Less than once a week	Once or twice a week	Three or more times a week
a. Cannot get to sleep within 30 minutes
b. Wake up in the middle of the night or early morning
d. Cannot breathe comfortably
e. Cough or snore loudly
f. Feel too cold
g. Feel too hot
h. Have bad dreams
i. Have pain
j. Other reason(s), please describe:

Do you have a bed partner or room mate?	No bed partner or room mate	Partner/room mate in other room	Partner in same room but not same bed	Partner in same bed


If you have a room mate or bed partner, ask him/her how often in the past month you have had:	Bot during the past month	Less than once a week	Once or twice a week	Three or more times a week
a. Loud snoring
b. Long pauses between breaths while asleep
c. Legs twitching or jerking while you sleep
d. Episodes of disorientation or confusion during sleep
e. Other restlessness while you sleep, please describe: