1. How many hours of sleep do you get on average?

Less than 5 hours 5-6 hours 7-8 hours More than 8 hours

2. How would you describe your sleep quality?

Poor – I wake up frequently Fair – I sometimes wake up feeling unrefreshed Good – I usually feel rested

3. Do you have difficulty falling or staying asleep?

Almost every night A few times a week Rarely

4. How often do you feel tired or low on energy during the day?

Almost every day A few times a week Rarely

5. Do you find stress affects your ability to sleep?

Very often Occasionally Rarely

6. Have you been told you snore or stop breathing during sleep?

Yes, frequently Occasionally Never