REMfresh Questionnaire

What best identifies your daily routine?

  • Work (Regular Hours)
  • Work the night shift, swing shift or have irregular work schedule
  • Frequent Traveler
  • None of the above

What are your issues with sleep?

  • Good. I woke up once or twice but was able to fall back asleep
  • Average. Some nights I sleep better than others
  • I have trouble falling asleep
  • Staying asleep most nights
  • Both trouble Falling and staying asleep
  • Terrible. What is sleep??

How frequently do you have these issues?

  • Once a month
  • Once a week
  • Twice or more a week
  • Everyday

Over the last week, how many hours of sleep a night have you been averaging?

  • 8 or more
  • 6-8 hours
  • 4-6 hours
  • 4 or less

What is your Age ?

  • 18-35
  • 36-55
  • 55-70
  • 70+

Does any of the following keep you up at night?

  • Stress
  • Aches and pains
  • Snoring
  • Your kids
  • Animals in the bedroom
  • Circular thoughts

How do you feel when you wake up in the morning?

  • It takes me a long time to get out of bed
  • I can get out of bed easily but still feel tired
  • I wake up feeling refreshed

Day time sleepiness?

  • I find myself nodding off during the day when I should be awake
  • I feel like I need to take a nap during the day
  • I don’t need to take a nap but I feel tired during the day
  • I am fully awake and alert during the day

Have you taken melatonin in the past?

  • Yes, it helps me fall asleep and stay asleep.
  • Yes, it helps me fall asleep BUT did not help me stay asleep.
  • Yes, it did not help me.
  • Yes, but I felt a side effect.
  • No.

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