Sleep Assessment Worksheet

Date

Name *

First

Last

Email *

Phone

Sleep Duration, Quality, & Effects

Check the box that applies best to you for each item

I have trouble falling asleep

I have trouble staying asleep

I take something to help myself sleep (e.g. herbal supplements, OTC drugs, prescription drugs, alcohol, etc.)

If so what? Please list any substances here

I have a medical condition that disrupts my sleep

I try to “catch up on sleep” on weekends or other times

I do shift work or otherwise have an irregular sleeping schedule

I worry about not getting enough sleep

I wake up early in my normal sleep cycle (e.g. 2-3 AM for a regular night-time sleeper)

If I wake up during my normal sleep cycle, I have trouble going back to sleep

I find it hard to wake up or get going after I wake up

I wake up with an alarm

I hit snooze on the alarm once or more

I depend on caffeine or other stimulants to stay awake and alert

My sleep is disturbed by factors outside my control (noise, children etc)

I seem to sleep OK, but wake up not feeling refreshed

I feel fatigued or have low energy when I’m awake

I don’t recover well from stress or physical demands

I feel moody, cranky, “down in the dumps”, and/or “blah”

I struggle to concentrate, learn, and/or remember things

I normally sleep

Left to my own devices, without having to accommodate someone else’s schedule, I’d consider myself

An early riser
A night owl
A mixture depending on how I feel

Sleep Practices

Check the box that applies best to you for each item

I take naps

I have a scheduled bedtime, or I plan my bedtime in advance

At least 30 minutes before bed, I purposely start winding down and preparing for sleep

I practice meditation or other forms of purposeful relaxation

I dim the lights or have darkness when it’s night time (or time to sleep)

I get bright light when I am supposed to be awake and alert (e.g. by going outside during the or having a light box.)

I don’t check work email or do other work-related activities within 1-2 hours of bedtime

I don’t engage in stimulating, energizing, or upsetting activities (e.g. intense workouts, first-person shooter games, etc.) within 1-2 hours of bedtime

I shut down all electronics* 30 minutes before bed (e.g. phone, TV, video games, etc.). *Optional: If I use a screen reader (e.g. a Kindle) to read before bed, I dim the screen brightness

I do something else to purposely prepare for sleep / bedtime

If so what?

Sleep Assessment Worksheet

Sleep Duration, Quality, & Effects

Sleep Practices

Coaching

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