Questionnaire on Sleep Habits

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Questionnaire: Sleep Habits Directions: Mark each blank with an X as it corresponds to you. Some questions are open ended and require a sentence or two response. Others as you to rate yourself or a statement as being True or False on a scale of 1-5, with 5 being the most True and 1 being the most False. All answers are completely confidential, no names are used, just numbers to codify the data. Demographics: Are you Male _____ Female ______ Age Group: Under 18 _____ 18-24 _____ 25-39 _____ 40-65_____ >65 _____ Is English your primary language: Yes_____ No_____ If no, what is your primary language? ____________________________ Which category best describes you? (You may check more than one) Full Time Student _____ Full Time Employed _____ Part Time Student _____ Part Time Employed Unemployed _____ What is your declared major? _______________ What is your approximate year in college? ______________ What is your approximate GPA? ________________ If a student, how many hours do you study, on average, a day? _________ General Health Questions: What is your height? ______________ Weight? _____________ Do you have any diagnosed sleep disorders? ________, If so, what are they? _______________________________________________________________ Do you snore? ________ Badly or loudly? _____________ Do you drink coffee or other caffeinated beverages? ______ How often a week? ______ Ever 1 hour before bed? ________ Describe: _____________________ Do you drink
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