What is your height in cm?
What is your weight in kg?
What is your gender?
What is your date of birth?
How would you describe your sleep (pick most applicable)?
What has been your key motivation to improve your sleep issues? (You can choose multiple)
How satisfied do you feel about your current sleep?
Have you ever discussed Sleep related issues with any of these? (You can choose multiple)
Do you use a wearable fitness tracker or similar health tracking device?
On average, how many hours of sleep do you get each night?
How satisfied do you feel about your current sleep?
During your sleep, which of the following applies to you? Select all that apply.
On average, do you experience these symptoms more than 3 times a week?
Have you experienced these symptoms for more than 3 months?
Do you feel that your sleep problems are interfering with your daily functioning?
Have you been told you snore?
If you can recall, which position do you usually snore in while sleeping?
Do you wake up with a dry mouth?
Do you sleep next to someone who snores?
Do you wake with headaches in the morning?
Even after sleeping through the night, do you feel sleepy during the day?
How sleepy do you usually feel during the day?
Have you ever been told you hold your breath while sleeping?
How often have you had trouble sleeping because of pain?
Have you ever experienced waking up coughing?
Do you ever wake gasping for breath?
Do you have high blood pressure or are taking medicine to treat it?
Do you experience heartburn or acid reflux, or take medication to treat it?
Have you been diagnosed with (or suffer from) any of these conditions?
Do you wake up with an aching jaw, or ever been told that you grind your teeth during sleep?
Do you sometimes feel that you have to move your legs to make them feel comfortable?
Have you heard of a common disorder called Sleep Apnea?
Do you believe that untreated Sleep Apnea has risk on your overall health?
Have you ever been diagnosed with Sleep Apnea?
If you recall, what was your diagnosed Apnea Hypopnea Index (AHI)?
Since your diagnosis, have you tried CPAP?
Are you currently using CPAP?
Would you be interested in speaking to a EdenSleep Sleep Coach to discuss options to improve your sleep?
Please select
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Male
Female
Prefer not to answer
Please select
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Light
Could be better
Disturbed
Deep
Great
Terrible
Yes
No
Less than 5 hours
5 to 7 hours
7 to 9 hours
More than 9 hours
Very satisfied
Satisfied
Moderately satisfied
Dissatisfied
Very dissatisfied
Yes
No
Yes
No
Not at all interfering
A little
Somewhat
Much
Very much interfering
Yes
No
On my back
On my side
In any position
Can't recall
Yes
No
Yes
No
Yes
No
Yes
No
Extremely
Moderately
Very
Slightly
Yes
No
Never
One or Twice a week
One or Twice a week
Three or more times a week
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Not sure
Yes
No
Not sure
Yes
No
Yes
No
Yes
No
AHI < 5
5 ≤ AHI < 15
15 ≤ AHI < 30
AHI ≥ 30
Don't recall
Yes
No
Yes
No
Yes
No
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