Name * First Name Last Name Age * Email * On average how many hours of sleep do you get per night? * less than 4 4-5 6-7 7-8 More than 8 What time do you usually go to bed? * What time do you usually wake up? Is your sleep schedule consistent on weekdays and weekends? Yes No How would you describe the quality of your sleep? Very poor Poor Fair Good Excellent Do you have trouble falling asleep? Yes No Do you have trouble staying asleep? Yes No Do you have trouble waking too early? Yes No Do you have trouble feeling rested when waking? Yes No How often do you wake up during the night? Never 1-2 times 3 or more times Do you nap during the day? Yes No If yes, how long? If yes, how many naps? How would you rate your stress level? Low Moderate High How would you use screens (TV, phone, tablet) before bed? Never Occasionally Frequently Always Do you consume caffeine (coffee, tea, soda) after 2pm? Yes No Do you take any medications or supplements that affect your sleep? Yes No If yes, please list Have you been diagnosed with any of the following? (Check all that apply) Sleep apnea Chronic pain Insomnia Diaabetes Anxiety or Depression Other If other please list Have you spoken to your doctor? Yes No If yes, what did they say? Are you currently under a healthcare provider’s care for sleep-related issues? Yes No What is your top sleep short-term concern or goal right now? What do you hope to learn or improve through sleep training? What are your long-terms goals regarding your sleep? Are you willing to commit to make changes to get better sleep and better health? I'm not sure I would love to chat about it. Absolutely! Thank you! Apply for Servicesinfo@blackgirlssleeping.com617-651-0821
