Sleep Quality Survey

Assess a patient's sleep patterns, quality, and potential sleep disorder symptoms. Helps clinicians identify insomnia, sleep apnea, and other sleep disturbances.

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Sleep Quality Survey

Answer the following questions about your sleep over the past month to help us evaluate your sleep health.

Patient Name*

How many hours of sleep do you typically get per night?*

Less than 5 hours5–6 hours7–8 hoursMore than 8 hours

How would you rate your overall sleep quality over the past month?*

How often do you have difficulty falling asleep?*

NeverLess than once a week1–2 nights a week3 or more nights a week

Sleep-related symptoms (select all that apply)

Loud snoringGasping or choking during sleepRestless legs or leg crampsWaking up frequentlyDaytime sleepiness or fatigue

Do you use any sleep aids?

Yes — prescription medicationYes — OTC medication or supplementsNo

Additional Comments about Your Sleep

Template Details

CategoryHealthcare

IndustryHealthcare

Fields7

Uses0

healthcaresleepinsomniasleep apneawellness