Insomnia
Are you having difficulty falling asleep at night?
Yes
No
Insomnia
Are you experiencing frequent wake ups during the night?
Yes
No
Insomnia
Are you having difficulty staying asleep?
Yes
No
Insomnia
Are you experiencing early morning wake ups?
Yes
No
Insomnia
Are you having trouble falling asleep again after waking up during the night?
Yes
No
Insomnia
Are you experiencing unrefreshing sleep?
Yes
No
Insomnia
Are you feeling tired or having little energy during the day?
Yes
No
Insomnia
Are you experiencing daytime drowsiness or falling asleep during the day?
Yes
No
Insomnia
Are you having difficulty concentrating during the day?
Yes
No
Insomnia
Are you experiencing mood changes such as irritability or depression?
Yes
No
Insomnia
Are you having trouble with memory?
Yes
No
Insomnia
Are you experiencing changes in your appetite or weight?
Yes
No
Insomnia
Are you having trouble with muscle tension or headaches?
Yes
No
Insomnia
Are you experiencing feelings of anxiety or stress that interfere with your ability to sleep?
Yes
No
Insomnia
Are you experiencing physical symptoms such as frequent urination or palpitations?
Yes
No
Insomnia
Are you having trouble with maintaining a regular sleep schedule?
Yes
No
Insomnia
Are you taking any medications that may be affecting your sleep?
Yes
No
Insomnia
Are you experiencing changes in your environment or daily routine that may be impacting your sleep?
Yes
No
Insomnia
Are you using any substances that may be affecting your sleep?
Yes
No
Insomnia
Have you had trouble sleeping for a month or more?
Yes
No
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