Women's Sleep Health Intake Questionnaire
Personal Information
Name
Age
Email
Phone
Occupation
Sleep Patterns
Typical Bedtime (Weekday)
Typical Wake Time (Weekday)
Typical Bedtime (Weekend)
Typical Wake Time (Weekend)
Average hours of sleep per night
Sleep Issues
Are you experiencing any of the following?
Trouble falling asleep
Trouble staying asleep
Frequent awakenings
Early morning awakening
Nightmares
Restless legs
Snoring
Pauses in breathing
None
Other sleep issues
Daytime Functioning
Do you experience any of the following during the day?
Fatigue
Difficulty concentrating
Mood changes
Morning headaches
None
Medical & Lifestyle Factors
Relevant medical conditions (e.g. pregnancy, PCOS, menopause, chronic pain, anxiety, depression, etc.)
Current medications, supplements, or sleep aids
Daily caffeine consumption (type and amount)
Alcohol consumption (frequency and amount)
Tobacco/nicotine use (form and frequency)
Exercise (type, frequency, time of day)
Additional Notes or Concerns