Skip to content

Take our free sleep health assessment

Identify how your sleep habits may be influencing your health. This brief, confidential assessment is a valuable first step toward better rest.

"*" indicates required fields

Name*

First Last

Phone*

Email*

Zip code*

Please enter a number from 00000 to 99999.

Preferred method of contact*

Email

Phone

How did you hear about us?*

Referral

Search engine

Social media

Other

Your Typical Sleep Habits

How many hours of sleep do you get on average each night?*

Less than 5

5-6

6-7

7-8

More than 8

How would you describe your sleep schedule consistency?*

Very consistent

Somewhat consistent

Inconsistent

How long does it usually take you to fall asleep?*

Less than 15 minutes

15-30 minutes

30-60 minutes

More than an hour

Sleep Quality & Daytime Functioning

How often do you wake up feeling rested?*

Almost always

Often

Sometimes

Rarely

Never

During the day, how often do you experience fatigue or low energy?*

Almost always

Often

Sometimes

Rarely

Never

During the day, how often do you experience difficulty concentrating or focusing?*

Almost always

Often

Sometimes

Rarely

Never

During the day, how often do you experience irritability or mood changes?*

Almost always

Often

Sometimes

Rarely

Never

Have you been told you snore or seen signs of breathing issues at night?*

Yes, regularly

Sometimes

No

Lifestyle & Health Insights

How much caffeine do you consume daily (coffee, tea, energy drinks)?*

None

1 cup

2-3 cups

4+ cups

Do you use screens (phone, tablet, TV) within 30 minutes of bedtime?*

Yes

No

Do you have medical conditions that might affect sleep (e.g., nasal congestion, chronic pain, anxiety)?*

Yes

No

Please describe what medical conditions you have that might affect sleep:

Do you have a history of hypertension?*

Yes

No

Your Sleep Goals

What is your primary reason for taking this assessment?*

Improve sleep quality

Shifting schedule / Insomnia

Snoring / Sleep apnea concerns

Daytime fatigue

Other

What is most important to you in seeking help for better sleep?*

Personalized care

Non-invasive solutions

Rapid relief

Affordable options

Expert guidance

CAPTCHA

Phone

This field is for validation purposes and should be left unchanged.

Δ

Sleep Disorders
About Us
Services
Sleep Supplies
Patient Resources
Connect

masonw@whitneysleepcenter.com

Whitney Sleep & Consultants

119 Graystone Plaza Suite 102
Detroit Lakes MN 56501

(218) 844 - 6150

Copyright © whitneysleep.com. All Rights Reserved.