MySleepDiary

Questions

Question 1: On a scale from 1-9 please indicate how sleepy you are feeling (Very alert=1,...,Very sleepy=9)

Question 2: How would you rate the quality of your sleep? (Very poor=1,...,Very good=5)

Question 3: What did you do in the hour before going to bed? (Reading=1,Internet=2,TV=3,Listening to music=4,Other=9,I prefer not to say=10)

Question 4: What time did you go to bed? (Answer: ____)

Question 5: When you got into bed, what did you do to try to sleep? (Reading=1,Internet=2,TV=3,Listening to music=4,Other=5,I prefer not to say=7)

Question 6: How long did it take for you to fall asleep? (Answer:___)

skipped question

Question 8a: If you had difficulty falling asleep, tap the box to specify why (Pain=1,...,Other=go to 8b)

Question 8b: Please specify (Answer: ____)

Question 9: What time did you wake up? (Answer: ____)

Question 10: How long did it take for you to get out of bed in the morning? (Answer:____)

Question 11a: Did you have frequent awakenings during the night that made it difficult to go back to sleep? (Yes=1,No=2)

Question 11b: Please specify (Answer: ____)

Question 12a: Did you take any medications before sleeping? (Yes=1,No=2)

Question 12b: Please specify (Answer: ____)

Question 13a: Is there anything else you would like to tell us that could have affected your sleep? (Yes=1,No=2)

Question 13b: Please specify (Answer: ____)

Question 1: Before going to sleep, how many sugary/caffeinated drinks did you have? (Caffeine: ____)

Question 1: Before going to sleep, how many sugary/caffeinated drinks did you have? (Soda: ____)

Question 2: Did you take a nap during the day? (Yes=1,No=2)

Question 2b: Okay, please specify (number of naps:____)

Question 2b: Okay, please specify (duration of nap in hours:____)

Question 2b: Okay, please specify (duration of nap in mins:____)