Preliminary Sleep Questionnaire:
Would you please take a few minutes to answer some questions about your sleep habits before we talk again to go through your plan. Your responses will help me prepare the plan and enable us to make the best use of our time together on our call. There are quite a few questions, but almost all of them can be answered in just a sentence or two, so please don't be intimidated! Just leave the ones blank that are not applicable. We may have touched on some of the questions in our initial phone call but it’s helpful to have all the information collated together to help create the plan. If you open this on a computer, you can just type the answers, save it, and return it as an attachment back to me (lynsey@flutterbysleepconsultancy.com) It would be great if you could have this back to me as soon as possible but at least 2 or 3 days before our consultation.
Sleep Questions:
Full Name
Age:
Email*
How long have you been experiencing sleep challenges and what issues do you struggle with? (E.g. Getting to sleep, night wakes (long or short), early waking? Anxiety around sleep)
How many days in a week do you feel you sleep poorly?
1
2
3
4
5
6
7
Have you spoken to your doctor about these issues? And, if so, what was the recommendation?
Do you have any other health problems I should know about?
Has anyone ever told you that you snore?
Yes
No
Do you take any sleep aides, prescription or over the counter? If so, how often?
Do you take any supplements?
Yes
No
Do any pets or partners sleep in bed with you?
Yes
No
Do you feel like you have enough room in your bed to move freely?
Yes
No
What portion of the night do you feel you sleep the best?
On a scale of 1 - 10, with 10 being so dark you can’t see your hand in front of your face, how dark is your bedroom?
1
2
3
4
5
6
7
8
9
10
How do you feel when you walk into your bedroom?
What time do you usually go to bed on weekdays? How consistent is this?
What is your current bedtime routine?
Tell me what you typically do the hour before bed.
What time do you have to get up?
Do you wake naturally or to an alarm clock?
What time do you go to bed on the weekends?
What time do you get up on weekends?
How do you feel when you get up in the morning?
How many times a week do you exercise? (is it at a similar time in the day…when?)
Is there a time in the day when you feel more alert?
Do you take a nap? If so, what time of the day, for how long and how often?
Have you noticed any changes in your menstrual cycle in the last 6 months?
Are you in menopause or perimenopause, or have you gone through menopause?
Do you ever wake up in the night feeling very sweaty?
How would you rate your stress level on a given day? On a scale of 1 to 5 with 5 being extremely stressed.
1
2
3
4
5
What areas of your life cause you to feel the most stressed?
Do you take any breaks throughout the day, and if so, when, and what do you do?
What is your favourite way to relax?
What do you love to do for fun?
Sleep Checklist:
I often complain to others about my poor sleep:
Yes
No
Sometimes
I repeatedly tell myself how tired I am throughout the day:
Yes
No
Sometimes
I often worry that I won’t sleep well on the night ahead, even if it’s only morning:
Yes
No
Sometimes
I feel a sense of dread when I see the clock approaching bedtime:
Yes
No
Sometimes
I have a bright clock in my room within view:
Yes
No
Sometimes
I often work or watch TV in bed:
Yes
No
Sometimes
I often wake up either cold or sweating:
Yes
No
Sometimes
I have a tendency to bring up heated or stressful conversations with my partner close to bedtime:
Yes
No
Sometimes
I have no bedtime, sometimes it’s 8:00 pm, sometimes it’s 1:00 in the morning:
Yes
No
Sometimes
Do you find you sleep better on weekends, when sleeping well doesn’t matter as much?
Yes
No
Sometimes
When you wake in the night do you lay there for long periods of time willing yourself back to sleep?
Yes
No
Sometimes
Do you constantly look at the clock in the night to see how much time you will have if you fall asleep right now?
Yes
No
Sometimes
Do you often work, check email or look at screens of any sort right until bedtime?
Yes
No
Sometimes
Do you have a consistent bedtime routine of about 20 min?
Yes
No
Sometimes
Do you believe that a sleepless night will ruin your entire next day?
Yes
No
Sometimes
Do you consume caffeine of any kind past 12:00 pm?
Yes
No
Sometimes
Do you drink more than one alcoholic beverage an hour before bedtime?
Yes
No
Sometimes
Do you get 30 min of physical activity a day (even just a light walk)?
Yes
No
Sometimes
Have you always slept poorly, even as a child?
Yes
No
Sometimes
Do you often reach for high sugar treats when you feel tired?
Yes
No
Sometimes
FEMALES ONLY NEED TO COMPLETE THE FURTHER QUESTIONS Hormone Questions:
Please scale if you have any of the symptoms below using between 1 and 5 (1 being not at all, 5 being very severe).
Low progesterone symptoms:
Depression/Anxiety:
1
2
3
4
5
Mood Swings:
1
2
3
4
5
Fatigue:
1
2
3
4
5
Low Libido:
1
2
3
4
5
Sleeping Difficulties:
1
2
3
4
5
Weight Gain:
1
2
3
4
5
Tender Breasts:
1
2
3
4
5
Hot Flashes:
1
2
3
4
5
Brain Fog:
1
2
3
4
5
Headaches:
1
2
3
4
5
Heavy Period:
1
2
3
4
5
Low Oestrogen symptoms:
Hot Flashes
1
2
3
4
5
Night Sweats:
1
2
3
4
5
Mood Swings
1
2
3
4
5
Depression/Anxiety
1
2
3
4
5
Dry Skin & Brittle Hair:
1
2
3
4
5
Weight Gain in the Belly:
1
2
3
4
5
Vaginal Dryness:
1
2
3
4
5
Increased UTIs:
1
2
3
4
5
Low Libido
1
2
3
4
5
Headaches
1
2
3
4
5
Fatigue
1
2
3
4
5
Frequent Urination:
1
2
3
4
5
Irregular Period:
1
2
3
4
5
Low testosterone symptoms:
Low Libido :
1
2
3
4
5
Difficulty Reaching Orgasm:
1
2
3
4
5
Vaginal Dryness
1
2
3
4
5
Fatigue :
1
2
3
4
5
Weight Gain
1
2
3
4
5
PMS Symptoms:
1
2
3
4
5
Heart Palpitations:
1
2
3
4
5
Difficulty Sleeping:
1
2
3
4
5
Loss of Muscle:
1
2
3
4
5
Loss of Bone Density:
1
2
3
4
5
Sluggishness Irregular Periods:
1
2
3
4
5
High testosterone symptoms:
Irregular Periods:
1
2
3
4
5
Acne:
1
2
3
4
5
Obesity:
1
2
3
4
5
Excessive Hair Growth:
1
2
3
4
5
Depression:
1
2
3
4
5
Deepening Voice:
1
2
3
4
5
Hair Thinning/Balding:
1
2
3
4
5
That's it – you made it! Thanks in advance for getting this back to me, and I look forward to our consultation call and getting you some much-needed sleep!
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