Sleep Assessment Welcome to the Sleep Assessment! Please check off each statement that applies to you. Each is worth 1 point. Name Email You always wake up too early in the morning yes noYou wake up frequently throughout the night to use the bathroom yes noYou have a hard time falling asleep yes noIt’s hard to get to sleep because you feel tense and can’t relax yes noYou wake up alert and ready to go between 2am and 4am and have a hard time getting back to sleep yes noYou cannot get to sleep due to constant ruminations and negative thought loops yes noYou seldom or never remember your dreams yes noYou’re a night-owl and like to stay up late yes noYou have frequent nightmares yes noYou are driven and energetic even though you sleep little yes noYou’ve had sleep problems since a prolonged period of stress or a single highly stressful event yes noYou are unable to quit using caffeine yes noYou have restless leg syndrome yes noYou have leg cramps yes noChronic pain when you are lying down keeps you from sleeping well yes noYour children’s insomnia keeps you from sleeping yes noYou frequently need tranquilizers like Xanax, Ativan, and Valium to get to sleep yes noYou frequently need Trazadone or Vicodin to help you sleep yes noYou frequently use diphenhydramine (Sleepinal or Dramamine) over-the –counter medication yes noYou need alcohol to sleep yes noYou have sleep apnea yes noYou use your phone, tablet, or computer after 7 PM yes noYou have bright indoor lighting yes noYour pets sleep with you yes noTime is Up!
