Calm Down Challenge Sleep & Anxiety Questionnaire

14 Day Chronic Fatigue Calm Down Challenge Sleep & Anxiety Questionnaire

The questions below give us a way of finding out where you are at right now with anxiety, overwhelm, or sleeping problems.

Please rate in this questionnaire:

In the last 4 weeks:

0 = Never / Not at all

1 = rarely / very mildly / 0-1 days per week

2 = sometimes / mildly / 2 - 3 days per week

3 = Often / moderately / 4 -5 days per week

4 = Almost always / severely / 6-7 days per week

Don't forget to take a screenshot for yourself and click submit at the bottom

Name:

Email:

Worry & Anxiety

I feel nervous or anxious

I cannot calm down and feel my thoughts spiralling out of control

I feel restless or fidgety, or cannot sit still

I experience panic and/or anxiety attacks

I have trouble relaxing

I worry about different things

I take pharmaceutical anxiolytic medications to help me relax

I take herbal and/or nutritional anxiolytic medications to help me relax

I become easily annoyed or irritable

I feel afraid that something awful might happen to me or my loved ones

Getting to Sleep

In the last 4 weeks:

0 = Never / Not at all

1 = rarely / very mildly / 0-1 days per week

2 = sometimes / mildly / 2 - 3 days per week

3 = Often / moderately / 4 -5 days per week

4 = Almost always / severely / 6-7 days per week

I have trouble falling asleep

I drink alcohol to help me get to sleep

I read, watch TV, or do things on my smart phone/digital device for more than 1 hour whilst in bed, before falling asleep

I take pharmaceutical sleeping medications to help me get to sleep

I take herbal or nutritional sleeping medications to help me get to sleep

I have restless legs and/or cannot keep my legs still when I am trying to get to sleep

I experience a creeping-crawling feeling or tingling in my legs when trying to get to sleep

I experience an inability to move when I am falling asleep or just awakening

I am generally more alert in the afternoons and evenings than in the morning

Thoughts start racing through my mind when I am trying to fall asleep

Staying Asleep

In the last 4 weeks:

0 = Never / Not at all

1 = rarely / very mildly / 0-1 days per week

2 = sometimes / mildly / 2 - 3 days per week

3 = Often / moderately / 4 -5 days per week

4 = Almost always / severely / 6-7 days per week

I awaken more than 1 time during the night

When I wake during the night I struggle to get back to sleep

I wake very early in the morning and can't get back to sleep

I sleep walk or move around a lot in my sleep

I have been told I jerk my legs and kick in my sleep

I dream vividly and/or have nightmares

I talk or shout in my sleep

Chronic pain interferes with my sleep

I grind my teeth in my sleep

I have to wake more than 1 time per night to urinate

Overall Quality & Quantity of Sleep

In the last 4 weeks:

0 = Never / Not at all

1 = rarely / very mildly / 0-1 days per week

2 = sometimes / mildly / 2 - 3 days per week

3 = Often / moderately / 4 -5 days per week

4 = Almost always / severely / 6-7 days per week

I awaken feeling unrefreshed or tired

I typically sleep for less than 7 hours per night

I do not go to bed and/or awaken at a regular time every day

I have been told I snore and/or I have woken myself up with my snoring

I awaken at night gasping for air and/or stop breathing whilst I sleep

I sweat a great deal at night

I awaken with headaches

I feel drowsy during the day

I take naps during the day

I perform poorly at work due to lack of sleep and/or drowsiness

Calm Down Challenge Sleep & Anxiety Questionnaire

Worry & Anxiety

Getting to Sleep

Staying Asleep

Overall Quality & Quantity of Sleep

Don't forget to take a screenshot for yourself and click submit below! Thanks for filling out this questionnaire.