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Sleep Questionnaire

Sleep is one of the most essential pillars of health and longevity.  This brief questionnaire helps you reflect on your sleep habits, patterns, and possible challenges so we can better understand the quality of your restorative rest.

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Please answer each question based on your typical sleep patterns.  There are no right or wrong answers -- only insights to guide your wellness plan.

Results will be sent to your email.

Sleep Schedule

Do you go to bed around the same time every night?
Do you wake up roughly the same time each morning?
Do you feel rested when you wake up?

Sleep Environment

Is your bedroom dark and quiet during sleep?
Is your bedroom comfortably cool at night?
Do you use electronic devices within an hour of bedtime?
Do you consume caffeine or alcohol in the evening?

Sleep Quality & Habits

Do you have difficulty falling asleep?
Do you wake frequently during the night?
Have you been told that you snore or stop breathing in your sleep?
Do you experience vivid dreams or nightmares?
Do you rely on medication or supplements to sleep?

Daytime Function

Do you feel fatigued or drowsy during the day?
Do you have trouble concentrating or remembering things due to poor sleep?
Have you ever fallen asleep unintentionally during the day?

Reflection & Consent

Consent & Acknowledgement

By submitting this form, I acknowledge that the information provided is truthful to the best of my knowledge. I understand that this questionnaire is for wellness and educational purposes only and does not establish a medical provider–patient relationship. I further understand that the results will be reviewed by Dr. Sandra McKenzie for the purpose of offering general wellness guidance or discussing next steps, and that any personalized recommendations will require a formal consultation.

This questionnaire is a screening tool, not a diagnosis.

Results help guide awareness and discussion.

Personalized recommendations require a clinical consultation.

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