Sleep & Circadian Optimization Activation

Sleep & Circadian Optimization Activation Form
Participant Details
Unique ID
Time zone
Contact method
Check-in day
Program start date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Goals and Readiness
Main sleep/circadian goals
Biggest challenge
Readiness to change

0

1

2

3

4

5

6

7

8

9

10

0 is Not ready, 10 is Fully ready
Goal summary
Baseline Schedule
Schedule variability (minutes)
Nap days per week
Nap duration (minutes)
Do you work shifts?
Do you have on-call duties?
Describe your shift pattern or on-call duties
Include AM/PM and your local time zone.
Typical shift start time

Hour Minutes

AM/PM Option
Typical shift end time

Hour Minutes

AM/PM Option
Upcoming travel or time-zone changes in the next 8 weeks?
Describe destination(s) and time-zone changes
Start date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
End date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Time zones
Chronotype
Usual bedtime on workdays

Hour Minutes

AM/PM Option
Usual bedtime on free days

Hour Minutes

AM/PM Option
Time to fall asleep (minutes) on workdays
Time to fall asleep (minutes) on free days
Night awakenings on workdays
Night awakenings on free days
Awake after sleep onset (minutes) on workdays
Awake after sleep onset (minutes) on free days
Final wake time on workdays

Hour Minutes

AM/PM Option
Final wake time on free days

Hour Minutes

AM/PM Option
Out-of-bed time on workdays

Hour Minutes

AM/PM Option
Out-of-bed time on free days

Hour Minutes

AM/PM Option
Total sleep time on workdays (hours)
Total sleep time on free days (hours)
Symptoms and Sleep History
How long have you had sleep difficulties?
How often do sleep difficulties occur?
Diagnosed sleep conditions

Other
Have you ever had a sleep study?
If yes, please provide details of your sleep study
Do you snore loudly?
Has anyone observed pauses in your breathing or gasping during sleep?
Do you wake with morning headaches or a dry mouth?
Do you experience restless legs or an urge to move your legs at rest?
Do you have nightmares, sleepwalking, or other unusual sleep behaviors?
If yes, please describe your nightmares or other sleep behaviors
Do you have excessive daytime sleepiness?
In the past 12 months, have you had drowsy driving or a near-miss event?
If yes, please describe the drowsy-driving or near-miss event
Medical conditions that may affect sleep
Are you currently pregnant?
Current medications and sleep supplements
Current sleep treatments, including CPAP or other devices, and how often you use them
Habits and Environment
Do you get morning outdoor light most days?
Do you use bright light or screens in the evening?
How dark is your bedroom at night?

1

2

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4

5

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7

8

9

10

1 is Very light, 10 is Very dark
How noisy is your bedroom at night?

1

2

3

4

5

6

7

8

9

10

1 is Very quiet, 10 is Very noisy
How comfortable is your bedroom temperature for sleep?

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4

5

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7

8

9

10

1 is Too cold, 10 is Too warm
How many servings of caffeine do you typically have per day?
What is the latest time you usually have caffeine?

Hour Minutes

AM/PM Option
Do you currently use any of the following?
If yes, please describe your alcohol, cannabis, or nicotine use
When do you usually exercise?
Include AM/PM and your local time zone.
When do you usually eat your last meal or snack?
Include AM/PM and your local time zone.
What is your usual wind-down routine before bed?
Are there any bed partner or caregiver considerations that affect your sleep environment?
Wearables and Data Sharing
Wearable device used
Willing to share sleep diary and wearable data
Consent
Signature
Should be Empty:

Sleep & Circadian Optimization Activation Form

Participant Details

Goals and Readiness

Baseline Schedule

Symptoms and Sleep History

Habits and Environment

Wearables and Data Sharing

Consent