Sleep & Circadian Optimization Activation
Participant Details
Unique ID
Time zone
*
Preferred contact method
*
Email
Phone
Text message
Preferred check-in day
*
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Desired program start date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Goals and Readiness
Primary sleep/circadian goals
Current biggest challenge
Confidence / readiness to make changes
Not ready
0
1
2
3
4
5
6
7
8
9
Fully ready
10
0 is Not ready, 10 is Fully ready
Primary sleep/circadian goal summary
Baseline Schedule
Typical schedule variability (minutes)
Number of nap days per week
Typical nap duration (minutes)
Do you do shift work or on-call work?
Yes
No
If yes, please describe your shift pattern or on-call responsibilities
Typical shift start time
Hour Minutes
AM
PM
AM/PM Option
Typical shift end time
Hour Minutes
AM
PM
AM/PM Option
Do you expect any upcoming travel or time-zone changes in the next 8 weeks?
Yes
No
If yes, please describe the destination(s) and expected time-zone changes
Travel start date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Travel end date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Expected time zones
Self-described chronotype
definitely morning
somewhat morning
neither
somewhat evening
definitely evening
Usual bedtime on workdays
Hour Minutes
AM
PM
AM/PM Option
Usual bedtime on free days
Hour Minutes
AM
PM
AM/PM Option
Estimated time to fall asleep (minutes) on workdays
Estimated time to fall asleep (minutes) on free days
Number of awakenings during the night on workdays
Number of awakenings during the night on free days
Time awake after sleep onset (minutes) on workdays
Time awake after sleep onset (minutes) on free days
Final wake time on workdays
Hour Minutes
AM
PM
AM/PM Option
Final wake time on free days
Hour Minutes
AM
PM
AM/PM Option
Out-of-bed time on workdays
Hour Minutes
AM
PM
AM/PM Option
Out-of-bed time on free days
Hour Minutes
AM
PM
AM/PM Option
Estimated total sleep time on workdays (hours)
Estimated total sleep time on free days (hours)
Symptoms and Sleep History
How long have you had sleep difficulties?
Less than 2 weeks
2-4 weeks
1-3 months
3-12 months
More than 1 year
How often do sleep difficulties occur?
Rarely
1-2 nights per week
3-4 nights per week
Most nights
Every night
Diagnosed sleep conditions
Insomnia
Obstructive sleep apnea
Restless legs syndrome
Circadian rhythm disorder
Narcolepsy
Parasomnia
Other
Have you ever had a sleep study?
Yes
No
If yes, please provide details of your sleep study
Do you snore loudly?
Yes
No
Not sure
Has anyone observed pauses in your breathing or gasping during sleep?
Yes
No
Not sure
Do you wake with morning headaches or a dry mouth?
Yes
No
Sometimes
Do you experience restless legs or an urge to move your legs at rest?
Yes
No
Not sure
Do you have nightmares, sleepwalking, or other unusual sleep behaviors?
Yes
No
If yes, please describe your nightmares or other sleep behaviors
Do you have excessive daytime sleepiness?
Yes
No
Sometimes
In the past 12 months, have you had drowsy driving or a near-miss event?
Yes
No
If yes, please describe the drowsy-driving or near-miss event
Medical conditions that may affect sleep
Are you currently pregnant?
Yes
No
Not applicable
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?
Yes
No
Sometimes
Do you use bright light or screens in the evening?
Yes
No
Sometimes
How dark is your bedroom at night?
Very light
1
2
3
4
5
6
7
8
9
Very dark
10
1 is Very light, 10 is Very dark
How noisy is your bedroom at night?
Very quiet
1
2
3
4
5
6
7
8
9
Very noisy
10
1 is Very quiet, 10 is Very noisy
How comfortable is your bedroom temperature for sleep?
Too cold
1
2
3
4
5
6
7
8
9
Too warm
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
AM/PM Option
Do you currently use any of the following?
Alcohol
Cannabis
Nicotine
None
If yes, please describe your alcohol, cannabis, or nicotine use
When do you usually exercise?
When do you usually eat your last meal or snack?
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
Please Select
None
Apple Watch
Fitbit
Garmin
Oura Ring
WHOOP
Samsung Galaxy Watch
Other
Willing to share sleep diary and wearable data
Yes
No
Concent
Signature
Submit Activation
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