About this template
This Insomnia Questionnaire is designed for healthcare professionals, therapists, and sleep clinics to streamline the patient intake process. By gathering structured data on sleep patterns, lifestyle habits, and symptom frequency, practitioners can quickly identify key areas of concern before a consultation begins. This template helps standardize the assessment process, ensuring that every patient provides the necessary background information in a consistent format.
Using this Google Form template allows you to collect critical data—such as sleep duration, daytime fatigue, and lifestyle factors like caffeine or alcohol intake—directly into a organized spreadsheet. This saves valuable time during clinical appointments, allowing providers to focus on diagnosis and treatment planning rather than manual data entry. Whether you are conducting a routine check-up or a specialized sleep study, this form provides a professional and accessible way to track patient progress over time.
Key features
- Standardized questions for consistent patient data collection.
- Covers sleep duration, quality, and lifestyle factors.
- Easy to share via email or patient portal links.
- Automatically saves responses to Google Sheets for analysis.
- Fully customizable to include your clinic's specific branding.
Use cases
- Initial intake for new patients at a sleep clinic.
- Tracking sleep quality improvements during therapy.
- Screening for sleep disorders in general practice.
- Gathering data for clinical research or medical studies.
What this form collects
- Full Name (Short answer)Please enter your full legal name.
- Age Range (Dropdown)Select your current age group.
- How many hours of sleep do you average per 24 hours? (Short answer)Include naps if applicable.
- How many nights per week do you experience poor sleep? (Multiple choice)Estimate based on the last month.
- Do you experience daytime sleepiness while at work or school? (Linear scale)Frequency of feeling drowsy during the day.
- How many days per week do you engage in physical exercise? (Multiple choice)Include any activity that increases your heart rate.
- Do you consume caffeine or alcohol regularly? (Checkboxes)Select all that apply.
- Additional Comments (Paragraph)Please share any other information regarding your sleep that you feel is important.
FAQ
How do I share this form with my patients?
Once you copy this template to your Google Drive, click 'Send' in the top right corner to get a link, which you can email directly to patients or embed on your secure clinic website.
Can I add my own questions to this template?
Yes, once the form is in your Google Drive, you can add, delete, or reorder any questions to better suit your specific clinical needs.
Where is the patient data stored?
All responses are stored directly in your personal Google Drive account, giving you full control over your data access and security.
Is this form suitable for mobile devices?
Yes, Google Forms are responsive by design, ensuring that your patients can easily fill out the questionnaire on their smartphones, tablets, or computers.
Get this form in your Google Drive
Save a copy to your Google Drive with one click (uses 1 credit). Or build from a PDF or description in the app.