Do you have a sleep problem?
Complete this quick screening questionnaire to receive some personalised feedback about your sleep quality from our clinical psychologist.
Sign in to Google to save your progress. Learn more
Name *
Email address *
Phone number *
Thinking about a typical night in the past month:
How long does it take you to fall asleep?
Clear selection
If you wake up during the night, how long are you awake for in total? (if you wake up more than once, add them up)
Clear selection
How many nights per week do you have a problem with your sleep?
Clear selection
How would you rate your sleep quality?
Clear selection
Thinking about the past month, to what extent has poor sleep...
... affected your mood, energy, or relationships?
Clear selection
... affected your concentration, productivity, or ability to stay awake?
Clear selection
... troubled you in general?
Clear selection
How long have you had a problem with your sleep?
Clear selection
Is there anything else you would like to tell us about your sleep?
Thank you for your time! Keep an eye on your email inbox for your personalised sleep feedback from our clinical psychologist.
Reference
Espie, C.A., et al. (2014). The sleep condition indicator: A clinical screening tool to evaluate insomnia disorder. BMJ Open, 4, e004183.
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Google Forms