Sleep Quality Assessment

QUIZ 15 Questions HOME PAGE

First Name

1. On average, how long does it take you to fall asleep once you're in bed ?

Less than 15 minutes

15 to 30 minutes

30 to 60 minutes

More than an hour

2. How often do you wake up during the night ?

Rarely or never

1 to 2 times per night

3 or more times per night

I wake up frequently and struggle to get back to sleep

3. On average, how many total hours of sleep do you get per night ?

7–9 hours

5–7 hours

Less than 5 hours

More than 9 hours but still tired

4. How do you feel when waking up ?

Very refreshed and alert

Slightly tired but functional

Extremely tired and fatigued

Exhausted, can barely function

5. How would you rate your overall sleep quality in the last 30 days ?

Excellent

Good

Fair/Poor

Terrible

6. How often do you experience daytime sleepiness or fatigue that impacts your activities ?

Rarely or never

Sometimes (1–2 times per week)

Frequently (3–5 times per week)

Daily, constantly affecting my life

7. Do you regularly use medication, alcohol, supplements, or aids to fall asleep ?

Never

Occasionally (1–2 times per week)

Frequently (3+ times per week)

Every night, I can't sleep without them

8. How often do you experience anxiety, stress, or racing thoughts at night ?

Rarely or never

Occasionally (once per week)

Frequently (multiple times per week)

Every night, severely impacting sleep

9. Has lack of sleep negatively impacted your relationships (family, partner, friends) ?

No impact

Minor impact, manageable

Significant tension or strain

Severe problems or frequent conflicts

10. Are you experiencing physical symptoms potentially related to poor sleep (e.g., headaches, pain, weight changes) ?

No symptoms

Mild occasional symptoms

Frequent, noticeable symptoms

Constant or severe symptoms

11. Do you have a consistent sleep schedule (bed/wake time) ?

Very consistent

Mostly consistent

Rarely consistent

Not at all consistent

12. How much screen time do you have in the last hour before bed ?

None or less than 15 minutes

15 to 30 minutes

30 to 60 minutes

More than 1 hour

13. Do you snore or stop breathing during the night (as observed by others) ?

No, never

Occasionally

Regularly

Yes, heavy snoring or breathing pauses

14. How comfortable and peaceful is your sleeping environment ?

Very comfortable and peaceful

Generally good

Often disturbed (light, noise, etc.)

Very uncomfortable or stressful

15. How motivated are you to improve your sleep ?

Extremely motivated

Somewhat motivated

Slightly motivated

Not motivated