Somnologie & Schlafcoaching GmbH

SELF-ASSESSMENT OF YOUR SLEEP SATISFACTION

Are you satisfied with your sleep?

not at all

rarely

sometimes

mostly

always

If your sleep needs improvement, what worries you? (check all that apply)?

Difficulties falling and staying asleep (insomnia)

Frequent or early awakening

Excessively long sleep

Unusual or disturbing behavior or experiences during sleep
(e.g., sleepwalking, snoring, fears, movements, vocalizations)

Excessive fatigue and daytime sleepiness

Difficulty sleeping and being awake at the desired times

Other problems or concerns, please describe:

How much does your quality of life suffer from sleep problems?

not at all

slightly

moderately

fairly

very much

How much do these complaints interfere with your ability to function at home, at work, or with others?

not at all

slightly

moderately

fairly

very much

How long have you had these sleep complaints?

One month or less

Between 1 and 6 months

Between 6 months and 2 years

Between 2 and 5 years

Longer than 5 years

What time do you usually go to bed?

Average time on weekdays (if variable: from - to): o'clock
Average time on weekends (if variable: from - to): o'clock

How much time thereafter do you turn off the light (close your eyes) to sleep?

After about: minutes

How long does it take you to fall asleep after lights off?

On average: minutes

How many times do you wake up per night?

About: time(s)

How long do you feel you are sleeping per night (minus any waking times)?

Approximately: hours

What time do you usually get out of bed to start your day?

On weekdays at about (if variable: from - to): o'clock
On weekends at about (if variable: from - to): o'clock

How important is it for you to have your sleep problems checked or treated?

not at all

slightly

moderately

fairly

very

Would you like to send your above answers to our Somnologie & Schlafcoaching practice for a short feedback?

Yes

How would you like us to contact you? (please provide an e-mail address or phone number):

Please let us know how to contact you.

The data collected will be forwarded to us by e-mail and never passed on to third parties. Refer to our privacy policy.

Inquiries and appointment

Consultations can take place in personal meeting on site or virtually via Zoom.

Send e-mail Call Make an appointment online

Our current flyer (in German)

PDF, 1.6MB
We are happy to send printed copies for display in your practice, clinic or other institutional health service (counseling, physiotherapy, fitness, etc.).
Folded flyer, 10x21cm.