Sleep Assessment Form Sleep Assessment Form Personal Information Email * Please enter a valid email address. Mobile Number First Name Last Name Address Town/Village City State Pin Code Country Gender Select Male Female Transgender Prefer Not to say 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) -------SELECT---------- Y N Blood Group Select O+ O- A+ A- B+ B- AB+ AB- 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? Sleep Assessment 1. At what time do you wake up on work days? * Before 4 am Between 4 am to 6 am Between 6 am to 8 am Between 8 am to 10 am Between 10 am to 12 pm After 12 pm Please select one option 2. At what time do you wake up on free days? * Before 4 am. Between 4 am to 6 am. Between 6 am to 8 am. Between 8 am to 10 am. Between 10 am to 12 pm. After 12 pm Please select one option 3. At what time do you sleep on work days? * Before 9 pm Between 9 pm to 10 pm Between 10 pm to 11 pm Between 11 pm to 12 am Between 12 am to 1 am After 1 am Please select one option 4. At what time do you sleep on free days? * Before 9 pm Between 9 pm to 10 pm Between 10 pm to 11 pm Between 11 pm to 12 am Between 12 am to 1 am After 1 am Please select one option 5. Ease of waking up assuming adequate environmental / physical conditions * Very easy Easy Not so easy Not at all easy Please select one option 6. Dependency on alarm clocks * Not at all dependent Slightly dependent Less dependent Highly dependent Please select one option 7. Time spent reading book / using phone / laptop / watching TV etc before going to bed * Less than 30 min 30 min - 1 hr 1 hr - 2 hrs Beyond 2 hrs Please select one option 8. Duration taken to fall asleep * Less than 15 min 15 min – 30 min 30 min – 1 hr Beyond 1 hr Please select one option 9. How alert do you feel in the first half an hour after waking up? * Most alert Alert Slightly alert Least alert Please select one option 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 Please select one option 11. How tired do you feel after first thirty minutes of waking up? * Least tired Slightly tired Tired Most tired Please select one option 12. There is every possibility of falling asleep during following situations in day time * Not applicable Sitting & Reading Between 6 am to 8 am Between 8 am to 10 am Between 10 am to 12 pm After 12 pm Please select one option Your message has been sent. Thank you! Your Sleep Requirement is: -NA- Your Sleep Efficiency is: -NA- Your Sleep Debt is: -NA- BMI: 0 Kg/m² Click to know all ranges BMR: 0 Calories/day Click to know all ranges
