CosmeticRx - Weight Loss Questions

Next, let's go through your health history.

What is your age?

18-24 25-34 35-44 45-54 55-64 65+

What is your gender?

Male Female Non-binary Prefer not to say

How would you rate your current sleep quality?

Excellent Good Fair Poor Very poor

How many hours of sleep do you typically get per night?

Less than 4 hours 4-5 hours 6-7 hours 8-9 hours 10+ hours

Do you have trouble falling asleep?

Never Rarely Sometimes Often Always

Do you wake up frequently during the night?

Never Rarely Sometimes Often Always

Do you have trouble staying asleep?

Never Rarely Sometimes Often Always

How often do you feel tired or sleepy during the day?

Never Rarely Sometimes Often Always

Do you currently take any sleep medications?

No, I don't take any sleep medications Yes, I take over-the-counter sleep aids Yes, I take prescription sleep medications Yes, I take both OTC and prescription medications

Do you have any of the following sleep disorders?

Select all that apply.

Insomnia Sleep apnea Restless leg syndrome Narcolepsy Circadian rhythm disorder None of the above

What time do you typically go to bed?

Before 9 PM 9-10 PM 10-11 PM 11 PM - 12 AM After 12 AM

What time do you typically wake up?

Before 5 AM 5-6 AM 6-7 AM 7-8 AM After 8 AM

Do you use electronic devices (phone, tablet, computer) within 1 hour of bedtime?

Never Rarely Sometimes Often Always

Do you consume caffeine after 2 PM?

Never Rarely Sometimes Often Always

Do you exercise regularly?

No, I don't exercise Yes, 1-2 times per week Yes, 3-4 times per week Yes, 5+ times per week

Do you have any medical conditions that might affect your sleep?

Select all that apply.

Depression Anxiety Chronic pain Heart disease Diabetes None of the above

How would you describe your stress level?

Very low Low Moderate High Very high

Are you interested in trying sleep medication to improve your sleep?

Yes, I'm very interested Yes, I'm somewhat interested I'm not sure No, I'm not interested