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Sleep Survey Template + Sample Questionnaire Template

The sleep survey template consists of various survey questions that collects data from a respondent about sleeping habits and causes and reasons of poor sleep in general. This survey consists of various survey questions aiming to understand the frequency of poor sleep and all the factors that cause it. It also collects feedback about the frequency of bad sleep and a respondent’s perceived reasons of sleeplessness. This questionnaire was also created by experts to understand from a respondent, the situations in which they would fall asleep rather than just feel tired or fatigued.


To what extent has poor sleep troubled you in general?
Which of these problems have you had with your sleep? Select all that apply
How many nights in a week do you have trouble with your sleep?
In the past 7 days, how many times have you slept for in-between 7-9 hours?
On an average, how many nights of sleep did you get per night?
How long have you had a problem with your sleep?
Did you sleep well as a child?
Please state your agreement with the following statements that are causing you to sleep less:
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
Work stress
Money problems
Relationship problems
Health problems
Drinking caffeinated drinks
Less to no exercise
Waking up to go to the bathroom
Sounds from outside the room
Sounds from inside the room
Temperature in the room
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
Trouble breathing
Having bad dreams
Watching TV before sleeping
Using a mobile/computer/laptop before sleeping
Smoking before sleeping
Consuming alcohol before sleeping
Working long hours
Working unorthodox hours
How likely are you to fall asleep in the day without ending to sleep? Or how likely are you to struggle to stay awake during the day?
How likely are you to fall asleep in the following situations rather than just feel tired or fatigued:
Very unlikely
Unlikely
Neutral
Likely
Very likely
Working in an office
Working on a site
Sitting and reading
Watching TV
Surfing the internet
Lying down without doing anything
As a passenger in a car
As a driver of a car
Stuck in traffic
Talking to someone
Very unlikely
Unlikely
Neutral
Likely
Very likely
Attending a meeting
Attending a call
Is there any other feedback you would like to provide?

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