"Your life is a reflection of how you sleep, and how you sleep is a reflection of your life."

-Dr. Rafael Pelayo

What time do you go to sleep?

Before 9pm

Between 9pm & midnight

Midnight to 3am

After 3am

How many hours do you sleep a night?

Less than 6

6-8

More than 8

On average how many minutes does it take to fall asleep?

Less than 10

10-30

More than 30 minutes

How deeply do you sleep?

Very deeply, it’s rare I wake up

I wake up sometimes for various reasons

Not deep at all, I regularly wake up

What do you normally do the hour before you go to sleep? (Select One)

Watch TV

On Internet/Computer

Eat

Exercise

Work

Drink Alcohol/coffee/tea or any other stimulants

Light, Relaxing Reading

Heavy, Stressful Reading

Meditate/pray

Yoga

Do you take sleep pharmaceuticals to help you sleep?

Yes

No

My room when I fall asleep has...

Lights on

TV On

Some ambient lighting

No light, is pitch black

Do you have trouble sleeping?

Always

Sometimes

Never

I exercise...

Daily

Moderately

Never

How do you normally feel the following day?

Sleepy, not rested at all

Somewhat rested, I burn out in the middle of the day.

Rested and ready to go

Please select an option

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