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The Affects of Bedtime Technology on the Body's Circadian Rhythm
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Age (in years)
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Today's date
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Gender
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Sleep Patterns
On weekdays, what time do you normally go to bed? (not sleep)
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On weekdays, what time do you normally fall asleep?
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On weekdays, what time do you normally wake up?
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On weekdays, what time do you normally get out of bed?
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During weekends, what time do you normally go to bed? (not sleep)
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During weekends, what time do you normally fall asleep?
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During weekends, what time do you normally wake up?
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During weekends, what time do you normally get out of bed?
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Do you consider yourself a night owl?
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Do you consider yourself a morning person?
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Do you usually feel that you could sleep for longer?
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How long does it take you to fall asleep, on average?
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Sleep Quality
During the last month, how would you rate your sleep quality overall?
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Do you feel that you could improve the quality of your sleep?
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Do you currently suffer from any of the following sleep disorders? (please select all that apply)
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Have you seen a doctor before about your sleep or a daytime alertness problem?
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During the last month, how often have you taken medicine to help you sleep?
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Do you need an alarm clock, the help of someone else or some other aid to wake you up in the mornings?
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During the last month, how often have you had trouble sleeping because you…..
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Sleep Environment
Do you usually share your bedroom with someone else when sleeping?
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Do you usually go to sleep with music, TV, etc on?
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Do you usually sleep with a light on in your bedroom?
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Where do you put your mobile phone when you go to bed?
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When falling asleep, if you hear your phone notification go off, how do you usually respond?
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Technology
At what age did you receive your first mobile phone?  (in years)
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How often would you say that you delay your bedtime due to using some form of technology (e.g.- mobile phone, computer, TV, PlayStation, etc.)?
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Do you feel anxious when separated from your mobile phone or tablet?
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Do you feel you need to be accessible by phone/tablet all day (including the night)?
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If so, do you find that feeling you have to be accessible by phone all the time is stressful or makes you feel anxious?
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Have you tried to reduce your use of technology in the bedroom late at night?
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If so, were you at all successful?
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Do you feel that electronic devices (e.g.- mobile phone, computer, TV, Xbox, etc.) affects your sleep in any way?
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Which technology do you feel is stopping you from getting the ideal amount of sleep that you need to function at your best?  (please select as many as you feel are relevant)
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Circadian Rhythm
How would you say your quality of sleep has affected your mood, energy levels or relationships?
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How would you say your quality of sleep has affected your concentration, productivity or ability to stay awake?
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How often would you say you have trouble getting to sleep?
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How often would you say you lie awake at night with your mind racing, feeling worried, anxious or depressed?
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Do you usually awake from sleep still feeling tired or sluggish?
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Do you usually awake from sleep still feeling irritable or angry?
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How often do you feel drowsy or unrefreshed during the daytime (including lesson times)?
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During the last month, how often have you had trouble staying awake in school, eating meals or engaging in social activity?
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Do you feel that your school performance may suffer because of sleepiness?
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During the last month, how much of a problem has it been for you to keep up enough enthusiasm to get things done?
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On a normal school day, when would you prefer to rise, if you were totally free to arrange your time?
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On a normal school day, when would you prefer to go to bed, if you were totally free to arrange your time?
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If you always had to go to bed at midnight, what do you think it would be like to fall asleep at that time?
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If you always had to get up at 06:00, what do you think it would be like to get up then?
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When do you usually begin to feel the first signs of tiredness and need for sleep?
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How long does it usually take you before you ‘come to your senses’ in the morning after waking up from a night’s sleep?
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Please indicate when you are most ‘active’ either in the morning or in the evening.
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