Sleep Readiness Name of the Patient *Name of the Doctor *Contact Number of Patient / Referring Doctor *Email Address *Date of Birth *Please describe how intensely you experience each of the symptoms mentioned below as you attempt to fall asleep by choosing appropriate alternative answer.1. How much you feel - Heart racing, pounding or beating irregularly. *Choose Out of 5 Alternatives Here, CarefullyExtremely / Very MuchMuchTo Some ExtentVery LessNot At All2. How much you feel - Shortness of breath or labored breathing. *Choose Out of 5 Alternatives Here, CarefullyExtremely / Very MuchMuchTo Some ExtentVery LessNot At All3. How much you feel - A tight, tense feeling in your muscles. *Choose Out of 5 Alternatives Here, CarefullyExtremely / Very MuchMuchTo Some ExtentVery LessNot At All4. How much you feel - Cold feeling in your hands, feet or your body in general. *Choose Out of 5 Alternatives Here, CarefullyExtremely / Very MuchMuchTo Some ExtentVery LessNot At All5. How much you feel - Have stomach upset (knot or nervous feeling in stomach, heartburn, nausea, gas etc.). *Choose Out of 5 Alternatives Here, CarefullyExtremely / Very MuchMuchTo Some ExtentVery LessNot At All6. How much you feel - Perspiration in palms of your hands or other parts of your body. *Choose Out of 5 Alternatives Here, CarefullyExtremely / Very MuchMuchTo Some ExtentVery LessNot At All7. How much you feel - Dry feeling in mouth or throat. *Choose Out of 5 Alternatives Here, CarefullyExtremely / Very MuchMuchTo Some ExtentVery LessNot At All8. How much you feel - Worry about falling asleep. *Choose Out of 5 Alternatives Here, CarefullyExtremely / Very MuchMuchTo Some ExtentVery LessNot At All9. How much you feel - Review or ponder events of the day. *Choose Out of 5 Alternatives Here, CarefullyExtremely / Very MuchMuchTo Some ExtentVery LessNot At All10. How much you feel - Depressing or anxious thoughts. *Choose Out of 5 Alternatives Here, CarefullyExtremely / Very MuchMuchTo Some ExtentVery LessNot At All11. How much you feel - Worry about problems other than sleep. *Choose Out of 5 Alternatives Here, CarefullyExtremely / Very MuchMuchTo Some ExtentVery LessNot At All12. How much you feel - Being mentally alert, active. *Choose Out of 5 Alternatives Here, CarefullyExtremely / Very MuchMuchTo Some ExtentVery LessNot At All13. How much you feel - Can't shut off your thoughts. *Choose Out of 5 Alternatives Here, CarefullyExtremely / Very MuchMuchTo Some ExtentVery LessNot At All14. How much you feel - Thoughts keep running through your head. *Choose Out of 5 Alternatives Here, CarefullyExtremely / Very MuchMuchTo Some ExtentVery LessNot At All15. How much you feel - A jittery, nervous feeling in your body. *Choose Out of 5 Alternatives Here, CarefullyExtremely / Very MuchMuchTo Some ExtentVery LessNot At All16. How much you feel - Being distracted by sounds, noise in the environment (e.g. ticking of clock, house noises, traffic). *Choose Out of 5 Alternatives Here, CarefullyExtremely / Very MuchMuchTo Some ExtentVery LessNot At AllPre-Sleep Arousal Scale (Markus Jansson-Fröjmark and Annika Norell-Clarke 2012) - Somatic Arousal OUT OF 35Pre-Sleep Arousal Scale (Markus Jansson-Fröjmark and Annika Norell-Clarke 2012) - Cognitive Arousal OUT OF 25Pre-Sleep Arousal Scale (Markus Jansson-Fröjmark and Annika Norell-Clarke 2012) - Meta Cognitive Arousal OUT OF 15SubmitPlease do not fill in this field.
