Sleep quality survey.

SLEEP quality Survey. ** Note this must be completed prior to starting on Sleep Drops.

This Sleep Quality Survey is important for you to do because the improvements in your sleep and sleep quality may be gradual and it is human nature for us to forget about how bad things have been once they are better.

Print this survey out and keep it in your health file.

Answer these questions honestly now before starting the Sleep Drops and again once you have finished the bottle.

Sleep Quality Survey
Please write the date in the first right hand column when you receive this survey your first bottle of sleep drops.  Then fill out the survey giving yourself a score of 1-10 (1 being low, 10 being high) when you answer the questions. Please write any answers that require comments underneath each question in the left hand column below. There are 2 lines, one for each date Please write the date in the far right hand column when you have taken the drops for one month, following the instructions on the bottle and following Kirsten’s sleep guidelines. Please give yourself a score of 1-10 when going through the questions again.	Date:		Date:
	Score 1-10	Score 1-10
Do you consider that you have trouble sleeping?
Do you consider that you have trouble sleeping?
On average how long does it take you to get to sleep from the time that you go to bed?	Time:	Time:
What time do you go to bed?	Time:	Time:
What time do you go to sleep?	Time:	Time:
Do you sleep all through the night?	Yes	No
If no then how many nights per week do you wake up on average?
If yes, then do you awake refreshed?	Yes	No
Comments:
Do you toss and turn in your sleep?	Yes	No
Do you snore, twitch or jerk yourself awake?	Yes	No
Do you wake in the night? If yes – how many times do you wake in the night?
If Yes - What time of night are you waking?	Time	Time
Are you waking to go to the toilet? or are you going to the toilet because you are awake? Think about this make sure this is correct.
If you do wake in the night, how long is it until you go to sleep again?	Time:	Time:
On a scale of 1 to 10. 1 being low and 10 being high how would you rate your current stress level?
How long have you been experiencing stress for?
Has your sleep been affected by your stress?	Yes	No
On the same scale 1 being low and 10 being high - how would you rate your energy levels throughout the day and evening?
Do you get tired throughout the day? If yes then what time(s) is it?
On a scale of 1 to 10. 1 being not so much and 10 being Very much - How would you rate the impact your lack of sleep is having on your life?
Sex drive?
Ability to socialise?
Play or be with your family?
Performance at work?
Other sleep related comments:

In order for you to apply for the "bottom of the bottle" money back guarantee refund should you be unlucky enough to have not responded positively to this Sleep Drops formula you will need to provide this information and complete this statement:

I _________________ hereby solemnly swear that I have had absolutely no improvement what so ever in my "sleep" and I have taken the Sleep Drops according to the instructions given to me by NZ Health Shop on both the label of the Sleep Drops product and the information and advice sheet provided and have implemented all of the advice and Sleeping strategies given to me.

Signed ______________________

Date:

Send to:

New Zealand Health Shop 74 St Mary's Rd. St Mary's Bay. AK 10111 or fax 093780444