Male
Female
Others
2.How long do you sleep on average every day
Less than six hours
Six to seven hours
Seven to eight hours
More than 8 hours
3.Do you have a regular sleep schedule(Fall asleep and wake up at similar times each day )
Yes
No
4.When you sleep, do you have the following symptoms
Easily roused from sleep
Difficulty falling asleep
Early morning awakening
Morning fatigue
Nightmare
Others
5.What factors do you think are contributing to your poor sleep quality
Use electronic devices before bed
Noise
physical condition
Diet
Psychological states
Others
6.Whether or not you use electronic devices in the half-hour before bed
Yes
No
7.Have you been affected by noise while falling asleep or during sleep?
Yes
No
8.Do you use any means (e.g. earplugs) to block out noise?
Yes
No
9.Whats your health condition?
I hardly ever get sick
I get a little sick sometimes
I get sick easily
I have a disease that is difficult to cure
10.When you have an illness, how often can you not sleep because of it?
Everyday
Many times a week
Never
11.Do you eat foods high in oil and fat within 4 hours of bedtime?
Yes
No
12.Do you consume anything exciting (coffee, cigarettes,drugs etc.) 4 hours before bed?
Yes
No
13. Do you easily roused from sleep or cant sleep because of stress or irritability?
Yes
No
14.Do you need medication to help you sleep? (includes medicines purchased by hospitals and pharmacies)
Yes
No