Do you have a sleep problem?

My work or other activities prevent me from getting at least 7 hours of sleep:
NeverOnce a Month1-3 Times a week3-5 Times a weekMore than 5 times a week

My bedtime or waketime varies by more than 3 hours:
NeverOnce a Month1-3 Times a week3-5 Times a weekMore than 5 times a week

It takes me 30 minutes or more to fall asleep:
NeverOnce a month1-3 Times a week3-5 Times a week5 time or more a week

I am awake for 30 minutes or more during the night:
NeverOnce a month1-3 Times a week3-5 Times a week5 time or more a week

I wake up 30 or more minutes before I have to and can’t fall back asleep:
NeverOnce a month1-3 Times a week3-5 Times a week5 time or more a week

I am tired, fatigued, or sleepy during the day:
NeverOnce a month1-3 Times a week3-5 Times a week5 time or more a week

Do you want to be able to fall asleep, stay asleep during the night, and sleep until your alarm sounds without having to rely on alcohol, sleep medicines, or other interventions?
YesNo

How long have you had this struggle with sleep?

In what ways is sleep a problem for you? Please describe.

Your Name (required):

Your Email (required):

Your Phone Number:

How do you prefer to be contacted?
EmailPhone

Your Zip Code* (required):

* Must live in Kansas or Missouri