1.)  How soon would you like to notice improved sleep express itself more regularly?
     6-8 weeks             4-6 weeks             2-4 weeks             Two weeks or less       

2.)  How many nights out of the week do you have a good night's sleep, where you wake up in the morning refreshed?
     6 or more nights             4-5 nights             3-4 nights             2 nights or less       

3.)  How long have you been experiencing sleep challenges?
     2 weeks or less             2-4 weeks             1-6 months             more than 6 months       

4.)  What are you using now to support improved sleep?
     Relaxation CD/White Noise       
     Non-Prescription Sleep aid/Herbs       
     Sleep medications for less than 6 months       
     Sleep medications for more than 6 months       

5.)  How long have you been using the support in the previous question?
     2 weeks or less             2-4 weeks             1-6 months             more than 6 months       

6.)  How many days of the week do you have periods of feeling anxious, worried, hurried, or overwhelmed?
     0-1 day             1-2 days             2-3 days             4 or more days       

7.)  If you scored 3 or 4 in the above question, how long have you been experiencing these periods?
(choose No Score if you have chosen 1 or 2 in the above question.)
     No Score             2 Weeks or less             2-4 Weeks             1-6 months             more than 6 months       

8.)  How many days of the week do you have periods of feeling helpless, depressed or somewhat

hopeless about your ability to make changes?
     0-1 day             1-2 days             2-3 days             4 or more days       

9.)  If you scored 3 or 4 in the above question, how long have you been experiencing these feelings?
(Choose No Score if you have chosen 1 or 2 in the above question.)
     No Score             2 Weeks or less             2-4 Weeks             1-6 months             more than 6 months       

10.)  How many days of the week do you have periods where you may feel like you are "running

out of gas," feeling tired physically or emotionally?
     0-1 day             1-2 days             2-3 days             4 or more days       

11.)  If you scored level 3 or 4 in the above question, how long have you been experiencing these feelings?
(Choose No Score if you have chosen 1 or 2 in the above question.)
     No Score             2 Weeks or less             2-4 Weeks             1-6 months             more than 6 months       

12.)  How many days of the week do you experience any one of the following:

  • Indigestion, heartburn, gas, bloating                   • Skin rashes

  • G.I. distress including diarrhea or constipation      • Headaches

  • Back, joint or body pain
     0-1 day             1-2 days             2-3 days             4 or more days       

13.)  If you scored 3 or 4 in the above question, how long have you been experiencing these feelings?
(Choose No Score if you have chosen 1 or 2 in the above question.)
     No Score             2 Weeks or less             2-4 Weeks             1-6 months             more than 6 months       

14.)  How many days out of the week do you feel productive and enjoy life?
     6-7 days             5 days             4 days             3 days or less       

15.)  If you scored 3 or 4 in the above question, how long have you been experiencing these feelings?
(choose No Score if you have chosen 1 or 2 in the above question.)
     No Score             2 Weeks or less             2-4 Weeks             1-6 months             more than 6 months       

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