Insomnia Survey

What is your diagnosis? (Please check all that apply.)

Please rank the severity of your insomnia.

What form of insomnia do you have? (Please check all that apply.)

What symptoms do you have during the night? (Please check all that apply)

What treatments have you tried to help your insomnia, and how well have they worked? (Please check all that apply.)

Much WorseA Little WorseNo EffectA Little BetterMuch BetterDon’t Know

How well did this work?

Much WorseA Little WorseNo EffectA Little BetterMuch BetterDon’t Know

Is there any single treatment or management technique you would recommend above all others?