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Insomnia Survey

* Name:
* Email:
Phone:
* Have you been diagnosed with any of the following:
Sleep Apnea
Restless Leg Syndrome
Chronic Fatigue
Narcolepsy
None of the above
* Rate your energy level in the morning:
Poor
Below average
Average
* Rate your memory and concentration:
Poor
Below average
Average
* Describe how well you sleep:
I get to sleep but don't stay asleep
I sometimes cannot get to sleep
I seem to sleep OK but still wake up tired
All of the above
* When at desk/driving, how likely are you to feel groggy?
I often get so sleepy I can barely keep my eyes open
Occasionally I get groggy while sitting
I'm always wide awake and alert during the day
* Rate your frustration/concern with your current symptoms:
Extreme
High
Moderate/Mild
Slight
None
* How many prescription drugs do you routinely take?
Five or more
Three or four
One or two
None
* What over the counter sleep aids do you use?
Tylenol PM
Nytol
Sominex
Compoz
Unisom
None
* What kind of doctor are you seeing about your poor sleep?
Primary care / Family doctor
Sleep specialist
I am not going to a doctor for this anymore
I have never seen a doctor about my sleep
* What other factors effect your sleep?
Acid burning feeling in my stomach or throat
I simply cannot get comfortable
My life is super stressful right now
I have to get up often to use the bathroom
* How likely are you to seek a new/second opinion about your sleep?
Very
Moderately
Slightly
Not at all
* How much is poor sleep, low energy or mental fog fouling up your life?
I feel like it's ruining my life
It's really bothering me
I wish it was better
I'm OK with it
* How important is it to you to find the cause of your sleep problem?
Very important - nothing else makes any sense
I am happy taking drugs for the symptoms