Sleep Assessment

Sleep Assessment Worksheet

This sleep assessment sheet will help you to better identify both the good and the not so good aspects of your sleep. Select the comments that describe your experiences with sleep. These responses are private and will help your sleep coach better understand and help improve your sleep.

Going to sleep:select the closest answer

I generally fall asleep immediatelyI generally fall asleep within 10 to 15 minutesI generally have a difficult time falling asleepI generally have a difficult time falling asleep because I tend to think or worryI have an almost impossible time falling asleep and often am awake for hours

Staying asleep:select the closest answer

I generally am able to stay asleep for the entire nightI generally awaken a few times per night but go back to sleep fairly easilyI tend to awaken a few times per night and have a difficult time going back to sleepI tend to awaken much too early and am often unable to go back to sleep

Sleep problems that I recognize:select ALL that apply

I worry or think too much at night and have a hard time stoppingI have aches and pains, leg movements or cramps that keep me awakeI have a sleep partner that snores or is restless and keeps me awakeLight from outside or noise sometimes keeps me awakePets or children sometimes keep me awakeI get up and eat during the night either without realizing it or in a way that seems difficult to stop or controlI often have bad dreams or nightmares that awaken meI walk or talk in my sleep or am told I act out my dreamsNone of the above

Sleep schedule and rhythms:select the closest answer

I pretty much go to bed and awaken at the same time each night and morningThere is some variation in my weekend sleep scheduleThere is a big difference in my weekend sleep scheduleI often have a hard time sleeping on Sunday nightIf I could sleep when my body wants to sleep I would go to bed much earlierIf I could sleep when my body wants to sleep I would go to bed much later and awaken much later in the morning

Symptoms that might have to do with sleep:select ALL that apply

I tend to be grumpy and impatientI tend to get sleepy during the day and fall asleep in meetings or in front of the TVI have fallen asleep while driving or at a stop lightI have a hard time maintaining a healthy weight and my appetite is hard to controlI snore very loud or have woken abruptly gasping for breathI have significant body pain and/or morning headachesWhen laughing or having strong emotions I occasionally feel like falling or actually fall downNone of the above

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For further information about our Sleep Coaching services please email sleepcoach@compeap.com call 1-800-344-1011.

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