Sleep Assessment Form

Email *

Mobile Number

First Name

Last Name

Address

Town/Village

City

State

Pin Code

Country

Gender *

Occupation

Date of Birth*

Time of Birth

Place of Birth

Place of Childhood

Ayam / Height (in cm) * Please enter a numeric and positive value only

Vistar / Breadth (in cm) Please enter a numeric and positive value only

Weight (in kg) * Please enter a numeric and positive value only

Weight Loss/Gain (Y/N)

Blood Group

Your existing medical condition (max 300 words)

Lifestyle diseases, if any please describe (max 300 words)

Family history of specific disease (max 300 words)

Do you require / consume any stimulants (max 300 words)

Consumption of sleeping pills (Y/N)

Any regular medicines going on for last one month?

Apart from this, would you like to add anything about yourself?

5) Ease of waking up assuming adequate environmental / physical conditions:*

Very easy
Easy
Not so easy
Not at all easy

6) Dependency on alarm clocks:*

Not at all dependent
Slightly dependent
Less dependent
Highly dependent

7) Time spent reading book / using phone / laptop / watching TV etc. before bed:*

Less than 30 min
30 min - 1 hr
1 hr - 2 hrs
Beyond 2 hrs

8) Duration taken to fall asleep:*

Less than 15 min
15 min – 30 min
30 min – 1 hr
Beyond 1 hr

9) How alert do you feel in the first half an hour after waking up?*

Most alert
Alert
Slightly alert
Least alert

10) How long does it take to attain complete alertness?*

Less than 15 min
15 min – 30 min
30 min – 45 min
45 min – 60 min
More than 1 hr

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