Sleep Questionnaire - FARE Hypnosis

Name

What do you expect to happen using hypnosis for better sleep?

What is your goal in regards to your sleep?

Tell me about your sleep issues? Can’t go to sleep? Can’t stay asleep or go back to sleep?

Use this scoring as it applies to the next 3 questions for the past week: 1-not at all; 2-a little bit; 3-somewhat; 4-quite a bit; 5-very much:

My sleep was restless

I was satisfied with my sleep

My sleep was refreshing

Use this scoring as it applies to the next 3 statement for the past week: 1-never; 2-rarely; 3-sometimes; 4-often; 5-always

I had difficulty falling asleep

I had trouble staying asleep

I had trouble going back to sleep

Overall, my sleep quality is: 1-very poor; 2-poor; 3-fair; 4-good; 5-very good

Why is it important to improve your sleep? On a scale of one to 10, what quality of sleep could help you live more comfortably?

What words would you use to describe your sleep? What words would you LIKE to use to describe your sleep?

When did your sleep issues begin?

What else was happening in your life at that time?

What treatments have you been given for sleep? Which of these were helpful? Which of these made the problem worse?

Do you think about your sleep issues during the day?

What makes your sleep issues worse?

What makes your sleep issues better?

What do you do when you can’t sleep?

What are you do for exercise (how much, how often)?

Comparing your life now to your life before your sleep issues, what did you stop doing completely that you used to do? Which of these activities would you like to do again?

Comparing your life now to your life before your sleep issues, what are you doing less of that used to do more of? Which of these activities would you like to start doing more of again?

Do others react when you are not sleeping well? If so, how?

What do you do now to cope with your sleep issues (if medications, what ones, at what doses)? How well do these coping strategies work for you?

What changes in your life if your sleep issues get better?