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First name:
Last name:
Birth date: (ex. 03/11/1976)
Zip Code:
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Phone: (ex. 866-205-1833)
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Sleep Hygiene Behavior Never Sometimes Usually Always
1. I "sleep in" when I have the chance.
2. I take naps during the day.
3a. I exercise late in the evening.
3b. I exercise regularly.
4. I work late in the evening.
5a. I smoke cigarettes or cigars in the evening.
5b. I drink caffeinated beverages in the evening.
6. I drink alcoholic beverages in the evening.
7. I eat late in the evening (within 3 hrs of bedtime).
8. I sleep uncomfortably (too noisy, hot, poor mattress, etc.).
9. I watch the clock at night when I can't sleep.
10. Light in my bedroom interferes with my ability to sleep longer in the morning.
11. My BMI is: (calculate BMI) .

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