Survey

Personnal data

Lastname*

Firstname*

Email*

Phone*

Gender*

Date of birth*

Weight (kg)*

Height (cm)*

Job title*

You live*

Alone

In couple

How many children live at home?*

Do you have breathing problems?

Do you snore or have noisy breathing while sleeping (at least 3 times a week)?*

Yes

Don't know

Has anyone around you noticed shortness of breath during sleep?**

Yes

Don't know

Are you sleepy ?

Drowsiness is not a simple feeling of tiredness but an intense struggle against the desire to sleep.

Do you experience excessive sleepiness or involuntary bouts of sleepiness (aside from naps you take) every day or almost every day?*

Yes

Don't know

Do you nap every day or almost every day?**

Yes

Are you bothered by the need to fight the urge to sleep during the day?*

Yes

Have you ever had an accident or near accident while driving during the day due to drowsiness or falling asleep in the last 6 months? *

Yes

Sleep periods

Are your sleeping hours very different from the usual social hours (e.g., very late bedtime or very early bedtime)? *

Yes

Spontaneously you do not sleep at night but in the morning and early afternoon*

Yes

Do you have any other troublesome and regular problems?

Do you have regular sleepwalking episodes (several times a month)?*

Yes

Don't know

Do you have frequent (more than once a week) nightmares and/or distressing dreams?*

Yes

At the beginning

Do you know exactly when your troubles started?**

Yes

Don't know

Signs of psychological orientation

Are you anxious?*

Yes

Don't know

Have you experienced a period of depression?*

Yes

Don't know

Are you currently experiencing depression?*

Yes

Don't know

HAD Survey

To answer these questions, please give the answer that best expresses how you have felt over the Nott week.

1 - I feel tense or irritated:*

2 - I enjoy the same things as before:*

3 - I have a feeling of fear as if something horrible is going to happen to me :*

4 - I laugh easily and see the good side of things :*

5 - I worry:*

6 - I am in a good mood:*

7 - I can sit quietly doing nothing and feel relaxed:*

8 - I feel like I'm in slow motion:*

9 - I have feelings of fear and a knot in my stomach:*

10 - I no longer care about my appearance:*

11 - I'm restless and can't stay put :*

14 - I can enjoy a good book or a good radio or television program:*

13 - I have sudden feelings of panic:*

14 - I can enjoy a good book or a good radio or television program:*

Your sleep schedule and habits

What time do you go to bed during the week?

between*

and*

At what time do you get up during the week?

between*

and*

What time do you go to bed during rest/holidays?

between*

and*

What time do you get up during your rest period/holidays?

between*

and*

When you go to bed, what do you do most often? (several answers possible)**

I seek sleep immediately

I have sexual activity

Read a book or magazine

I use my phone/tablet/computer to communicate with others (SMS, email, social networks) or for work

I keep my smartphone on next to me

I watch television

Other

How long does it take you to fall asleep?*

If you wake up during the night, how long do you stay awake?*

How many hours of sleep do you think you need?**

Current medication(s)

Do you take medication to sleep?**

Yes

If possible, specify medications used. If none, leave blank.

If this questionnaire does not accurately describe your sleep, please specify :

Please specify your socio-professional category or activity:*

If you are working, please specify your occupation:

Do you work night shifts?*

Yes

Do you work hours that require you to go to bed very late or very early?*

Yes

Drowsiness is not a simple feeling of tiredness but an intense struggle against the desire to sleep.

We ask you to specify here how you perceive your symptoms, by placing yourself on a scale of evaluation going from 0 to 10.

To answer these questions, please give the answer that best expresses how you have felt over the Nott week.

Sleep disorders suffered by your parents, brothers and sisters

Are you currently being treated for :

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