😴
Healthcare & Wellness
Sleep Quality Assessment
Understand a client's sleep patterns and problem areas before a sleep-coaching or insomnia consult.
Use this template10 fields · Free · Customize before publishing
What this form looks like
Preview · not interactiveSleep Quality Assessment
Understand a client's sleep patterns and problem areas before a sleep-coaching or insomnia consult.
Your name*
Jane Doe
Email address*
Your sleep summary and next steps go here.
What time do you usually go to bed?*
Pick a date📅
On a typical weeknight — lights out, not just in bed scrolling.
What time do you usually wake up?*
Pick a date📅
How much sleep do you actually get on an average night?*
Pick a date📅
Your honest estimate of time asleep — not time in bed.
How often do you experience each of these?*
Never1–2 nights a week3–5 nights a weekNightlyTrouble falling asleep (over 30 minutes)Waking during the nightSnoring or gasping (per you or a partner)
Caffeinated drinks per day
Coffee, tea, cola, energy drinks — everything counts.
Do you use a phone, tablet, or TV in the hour before bed?
Select…▾
Overall, how would you rate your sleep quality?*
★★★★★
How refreshed do you feel when you wake up?
Running on emptyFully recharged
Submit