Sleep Robber Checklist
The following is a simple checklist to critique your sleep ambiance and help you determine to what extent good quality sleep is being robbed from you. On a scale of 1-5 (1=very poor, 5=excellent), please rate your sleep environment based on these factors. Anything less than good can be a red flag.  

Keep a tally of the number you choose for each question as the next section will provide a score.
1= Very Poor, 2= Poor, 3= Fair, 4= Good, 5= Excellent
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1- Light/darkness factor *
Very Poor
Excellent
2- Noise factor *
Very Poor
Excellent
3- Temperature factor *
Very Poor
Excellent
4- Bedding factor *
Very Poor
Excellent
5- Routine/ritual *
Very Poor
Excellent
6- Technology (phone, iPad, etc.) *
Very Poor
Excellent
7- Television in bedroom *
Very Poor
Excellent
8- TV watching before sleep *
Very Poor
Excellent
9- Meals close to bedtime *
Very Poor
Excellent
10- Sleeping partner *
Very Poor
Excellent
11- Pets *
Very Poor
Excellent
12- Caffeine intake before bed *
Very Poor
Excellent
13- Chronic pain *
Very Poor
Excellent
14- Medications *
Very Poor
Excellent
15- Naps during the day *
Very Poor
Excellent
16- Other____________ *
Very Poor
Excellent
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