Chronotype Assessment
INSTITUTE OF CHRONOBIOLOGY EDUCATION & RESEARCH

Following questionnaire will assess your sleep-wake pattern and daily behavior so as to provide you the feedback about your chronotype or behavioral phenotype in prescribed format.

The analysis will be useful for knowing and adjusting your disturbed biological clock.
A disrupted biological clock is the root cause of all lifestyle diseases whereas a normal biological clock is the key for sound health in the technology driven society.

Your response will be used for research purpose only and analysis report will be sent to you within one week on the email address provided by you.


CONSENT

I, the undersigned, voluntarily agree to take part in the study.

I have been given a full explanation by the scientific investigators of the nature and purpose of the study.

I have been given the opportunity to question the investigators on all aspects of the study, and have understood the advice and information given as a result.

All documentation held on a volunteer is in the strictest confidence and complies with the Data Protection Act (2013). I agree that I will not seek to restrict the use to which the result of the study may be put.

I confirm that I have read and understood the above and freely consent to participating in this study. I have been given adequate time to consider my participation and agree to comply with the instructions and restrictions of the study.


INSTRUCTIONS

a) Please read each question very carefully before answering.
b) Answer all questions in numerical order.
d) Each question should be answered independently of others. No need to go back and check your answer.
e) For each question select one answer only.
f) Please answer each question as honestly as possible.
g) Please complete all of the following sections, regardless of whether you are working on a regular basis or not.

Email address *
Name
Your answer
Time of birth *
Your answer
Gender *
Your answer
Age (yrs) *
Your answer
Height (cm) *
Your answer
Weight (kg) *
Your answer
Blood group *
Your answer
Postal address (city, country, pin code) *
Your answer
Current occupation *
Shift work (other than 8 am - 5 pm job) in last three months (if yes, please mention nature of work) *
Your answer
1. At what time do you wake up on work days *
2. At what time do you wake up on holidays *
3. At what time do you sleep on work days *
4. At what time do you sleep on holidays *
5. Ease of waking up assuming adequate environmental / physical conditions *
Very easy
Not at all easy
6. Dependency on alarm clocks *
Not at all dependent
Highly dependent
7. Time spent reading book / using phone / laptop / watching TV etc before going to bed *
8. Duration taken to fall asleep *
Very short
Very long
9. How alert do you feel in the first half an hour after waking up *
Most alert
Least alert
10. How long does it take to attain complete alertness *
11. How tired do you feel after first thirty minutes of waking up
Least tired
Most tired
12. For some reason you have to go to bed several hours later than usual, but there is no need wake up at any particular time next morning. You will prefer *
13. One night you have to remain awake between 4 am to 6 am. You have no commitments next day, which suits you best? *
14. You are required to be at your peak for a test which is going to be a mentally exhaustive test and lasting for two hours. Which two hours you will prefer, if you were free to plan your day? *
15. If you were to work for 5 hours, what time slot would you prefer the most? *
16a. What are your actual working hours(includes both mental/physical) - For housewives and retired person *
16b. What are your actual working hours (includes both mental/physical) - For students *
16c.What are your actual working hours (includes both mental/physical - For professionals *
17. When are you most active during your working hours *
18. When are you most tired during your working hours *
19. You have to do hours of physical work, which hours would you prefer to do it between *
20. You have decided to engage in some physical exercises, a friend suggests that you do this between 10.00 pm to 11.00 pm in the night twice a week. How do you think, you would perform *
Very difficult
Not at all difficult
21. Do you require / consume any stimulants *
22. Do you consume sleeping pills *
23. How many hours of natural light are you exposed to on working days *
24. How many hours of natural light are you exposed to on holidays. *
25. How many hours of artificial lights (other than sunlight, including gadgets screen) are you exposed to on working days *
26. How many hours of artificial light (other than sunlight, including gadgets screen) are you exposed to on holidays *
27. For menstruating women: Is your cycle regular
28. For menopausal women: Age at the menopause
29. How many meals do you take on work day *
30. Time of your dinner on work day *
31. Do you suffer any of the lifestyle diseases (if yes, please give name/s) *
Your answer
32. Enlist the name of medicines taking regularly for last one month *
Your answer
33. Please affirm that all the above responses represents the most frequent daily schedule by writing your initials along with date.
Your answer
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