Insomnia - v2

Which therapist referred you?

• Peter Forster
• Andrea Starn
• Chris Restivo
• Alana Kivowitz
• Jasmine Teleki

Before going to bed, which of the following have you ever done in order to help you get sleepy?

• taken a medication
• eaten a snack
• taken a bath
• read
• exercised
• used relaxation exercises
• slept with a fan blowing (or other noise)

When in bed, prior to going to sleep or during the night if you have difficulty sleeping, do you...Choose all that apply.

• read
• watch TV
• listen to music or the radio
• check the time on your clock during the night
• feel anxious, have muscle tension, or feel like your body cannot relax
• have racing thoughts going through your mind which keep you from sleeping
• feel bothered by problems in your sleeping environment such as an uncomfortable mattress or the light in your room (too much or too little), or traffic or outside noises

Do you sleep with another person or a pet?

• Yes
• No

Does your bed partner ever cause you to have problems sleeping?

• Yes
• No
• Not Applicable

What size is your bed?

• King
• Queen
• Double (Full)
• Twin

When you are in bed and awake, do you think about...Choose all that apply.

• Trying to fall asleep
• Family matters
• Work

Do you ever become annoyed or angry when you cannot get to sleep?

• Yes
• No

Do you sometimes get out of bed if you cannot get to sleep?Please use the comments field to describe how often you do that, under what circumstances, and what you do if you get out of bed.

• Yes
• No

Comments

As your bedtime approaches, do you become more alert?

• Yes
• No

During the day, do you worry about getting to sleep the next night?

• Yes
• No

If you sleep away from home for a night or two do you:

• sleep better
• sleep worse
• sleep about the same