Fillable FxNA sleep assessment (City of Oakland)

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FxNA sleep assessment (City of Oakland)

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HANDOUT © FUNCTIONAL NUTRITION ALLIANCE LLC PAGE 1 OF 2
SLEEP HISTORY
While “sleep troubles” are often lumped together as one singular symptom, the reasons leading to your
inability to catch those nightly Zzzzs can be varied. Help us to target our recommendations to your unique
needs by taking a moment to answer these key sleep questions and assessments.
1. Are you satisfied with your sleep?
2. Do you feel rested in the morning?
3. Do you stay awake all day without dozing?
4. Do you fall asleep in less than 30 minutes?
5. Do you sleep between 6 and 8 hours per night?
6. Do you have a regular bedtime? (If so, when?)
7. Do you have a regular awakening time? (If so, when?)
8. Do you wake in the middle of the night? (If so, is there a regular
waking time and how long are you awake?)
9. Are you asleep (or trying to sleep) between 2:00 a.m. and 4:00 a.m.?
FxNA sleep assessment
HANDOUT © FUNCTIONAL NUTRITION ALLIANCE LLC PAGE 2 OF 2
10. Do you currently have any practices that enhance the quality of your sleep?
11. What have you tried (habits, supplements, etc.) to remedy sleep troubles in the past?
12. What (if any) electronics are in your room at nighttime?
13. On a scale of 1–10, how dark is your bedroom?
14. Do you consume any stimulants during the day? If so, when?
15. Please identify how you would most generally categorize your sleep troubles:
MIND (racing, working, etc.), BODY (pain, discomfort, etc.), or SPIRIT (depression,
anxiety, etc.).
SLEEP SYMPTOMS SCALE
Rate how often you experience each of the following symptoms using the following
frequency scale:
0 = never 1 = monthly 2 = weekly 3 = daily
0 1 2 3 0 1 2 3
❍ ❍ ❍ ❍ Daytime sleepiness
❍ ❍ ❍ ❍ No dream recall
❍ ❍ ❍ ❍ Sleepwalking
❍ ❍ ❍ ❍ Nightmares
❍ ❍ ❍ ❍ Snoring
❍ ❍ ❍ ❍ Sleep apnea
FxNA sleep assessment, continued
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Completed 23 April 2022

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