The Wild Movement > Sleep and Stress

Sleep and Stress

Sleep and Stress

Please take your time to fill out this form, it should only take a few minutes and helps us to better cater to your needs. All information remains strictly confidential.

Step 1 of 3 - Personal details

Personal details
Name*
First name Last name
Email address*
Mobile number*

Sleep
Do you have trouble falling asleep at night?
Do you have difficulty waking in the morning?
Do you sleep less than 8-9 hours per night?
Do you wake up once or more during the night?
Do you sleep in a room with any light or noise?
Do you wake up tired?
Do you need an alarm to wake up?
- Yes
- No
Do you go to bed later than 11pm and get up earlier than 6am?
Do you use medications – over the counter or prescriptions to sleep?

Stress
Has your Dr ever told you you have high or Low Pressure?
How would you say your ability to cope with stress is?
How would you say your ability to concentrate is?
Would you say you generally feel:
- Happy
- Neutral
- Frustrated
- Sad
Anything else you would like to share?
Phone
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