Sleep Quality Survey

Sleep Quality Survey — Form Fields

This healthcare template includes 7 fields. Assess a patient's sleep patterns, quality, and potential sleep disorder symptoms. Helps clinicians identify insomnia, sleep apnea, and other sleep disturbances. Free to customize and use on ZenBuild.

• Patient Name (text, required)
• How many hours of sleep do you typically get per night? (multiple choice, required) — options: Less than 5 hours, 5–6 hours, 7–8 hours, More than 8 hours
• How would you rate your overall sleep quality over the past month? (rating, required)
• How often do you have difficulty falling asleep? (multiple choice, required) — options: Never, Less than once a week, 1–2 nights a week, 3 or more nights a week
• Sleep-related symptoms (select all that apply) (checkboxes, optional) — options: Loud snoring, Gasping or choking during sleep, Restless legs or leg cramps, Waking up frequently, Daytime sleepiness or fatigue
• Do you use any sleep aids? (multiple choice, optional) — options: Yes — prescription medication, Yes — OTC medication or supplements, No
• Additional Comments about Your Sleep (long text, optional)