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Name * First Name Last Name Email * Phone * Country (###) ### #### ***Study Habits Assessment*** What kind of book would you read for fun? * A book with lots of pictures A book with lots of words A book with word searches or crossword puzzles What do you do when you're not sure how to spell a word? * Write it down to see if it looks right Spell it out to see if it sounds right Trace the letters in the air When waiting on line to purchase clothes, what are you most likely to do? * Look around at other clothes on the rack Talk to the person next to you in line Fidget/move back and forth When you see the word 'cat', what do you do first? * Picture a cat in your mind Say the word 'cat' to yourself Think about petting a cat or hearing it purr What's the best way for you to study for a test? * Read the book or your notes and review pictures or charts Have someone ask you questions that you can answer out loud Make up index cards that you can review What's the best way for you to learn about how something like a computer or video game works? * Get someone to show you Read about it or listen to someone explain it Figure it out on your own If you went to a school dance, what would you be most likely to remember the next day? * The faces of the people who were there The music that was played The dance moves you did and the food you ate What do you find most distracting when you are trying to study? * People walking past you Loud noises An uncomfortable chair When you're angry, what are you most likely to do? * Put on a "mad" face Yell and scream Slam doors When you're happy, what are you most likely to do? * Smile a lot Talk a lot Act really hyper When you're in a new place, how do you find your way around? * Look for a map or directory that shows where everything is Ask someone for directions Start walking around until you find what you're looking for Of these three classes, which is your favorite? * Art class Music class Gym class When you hear a song on the radio, what are you most likely to do? * Picture the video that goes with it Sing or hum along with the music Start dancing or tapping your foot What do you find most distracting when in class? * Lights that are too bright or too dim Noises from the hallway or outside the building The temperature being too hot or cold What do you like to do to relax? * Read Listen to music Physical activity (e.g., walk, run, play sports) What is the best way for you to remember a phone number? * Picture the numbers on the phone as if you were dialing them Say the number out loud over and over Write it down or store it in your phone If you won a game, which of these prizes would you choose? * A poster for the wall A music subscription service gift card A game, football or soccer ball Which would you prefer to go to with a group of friends? * A movie A concert An amusement park What are you most likely to remember about new people you meet? * Their faces but not their name Their name but not their face What you talked to them about When you give someone directions to your house, what are you most likely to tell them? * A description of buildings and landmarks they'll pass The names of the roads or streets they'll be onOption 2 Tell them "follow me - it'll be easier if I just show you how to get there" ***Sleep Habits Assessment*** What is your required/preferred wake up time? (Ideally, you should wake up at the same time daily) * When do you feel most alert? * Early morning, before noon Mid-morning to early afternoon Late morning to early afternoon Late afternoon to evening How easily do you wake up in the morning? * Super easily Relatively easily Waking up in the morning is quite a challenge Waking up isn't easy because I never get a good night's sleep Would you consider yourself a morning person? * Definitely Mostly Not really Not at all Do you hit the snooze button? * I don't need an alarm to wake up I use an alarm, but I don't hit the snooze button I use an alarm and sometimes hit the snooze button I use an alarm and hit the snooze button multiple times What time do you naturally wake up without an alarm? * Before sunrise When the sun comes up It varies As late as possible What do you do first thing in the morning? * Jump out of bed and get ready for my workout Get some sun first Lay in bed and try to wake up Hit the snooze button When do you feel most productive? * 7am-11am 9am-1pm 10am-2pm 12pm-4pm How often do you feel tired throughout the day? * Usually just in the mornings Afternoons and evenings Usually just in the evenings Always When do you prefer to exercise or be active? * First thing in the morning Mid-morning Early to late afternoon Evenings Which best describes your personality? * Driven and highly productive Extroverted and personable Creative and impulsive Perfectionist and scatterbrained What's your energy level like in the evening? * Very low Relatively low Moderate to high High Around what time do you usually go to bed? * I'm asleep by 10pm Between 10pm-11pm Midnight or later Whenever I feel like it How easily do you fall asleep? * I fall asleep almost immediately I usually don't have a problem falling asleep It takes me awhile to fall asleep It varies Is your sleep easily disrupted? * Definitely Not typically It sometimes is, but I fall back asleep easily Not at all Have you ever been diagnosed with a sleep disorder? * Yes No No, but my sleep schedule changes on the weekends No, but I might have one ***Stress Assessment*** How overwhelmed do you feel by your daily responsibilities? * Rarely Once in a while Often All the time How often do you feel irritable, anxious or on edge? * Rarely Once in a while Often Never Are you having trouble sleeping or are you experiencing changes in your sleep patterns? * Rarely Once in a while Often Never Do you find it difficult to concentrate or make decisions lately? Yes No Do you find it hard to relax or unwind at the end of the day? * Rarely Once in a while Often Always ***Nutrition Assessment*** How often do you eat within an hour of going to bed? * Rarely Once in a while Often Never What foods or snacks do you typically consume before bed? * What kind of beverages do you drink throughout the day? * Only water Water and other sugary and/or caffeinated drinks Mostly sugary and/or caffeinated drinks Have you noticed any changes in your weight or health that might be related to eating before bedtime? * Yes No Not sure Do you pay attention to portion sizes when eating, or do you eat until you feel satisfied? * I pay careful attention to portion size I try to pay attention to portion sizes but sometimes eat more I usually just eat till I feel like stopping Thank you!
