What do you have trouble with when sleeping?
Choose as many as you like
Falling asleep
Staying asleep
Waking up too early
Something else
Have you been diagnosed with any of the following?
Choose as many as you like
Sleep Apnea
Restless Leg Syndrome
Bipolar Disorder
Circadian Rhythm Disorder
None of the above
How long have your sleeping problems lasted?
Under a month
1-3 months
3+ months
How often do your sleep problems affect you?
Choose as many as you like
Once a month
1 or 2 nights a week
More than 2 nights a week
Do you currently take any of the below to help you sleep?
Choose as many as you like
Prescription medication
OTC sleep aids
Supplements
Are you 21 years of age or above?
Yes
No
What is your Evry insurance member id?
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