SWI: MELATONIN DEFECIENCY TEST

MELATONIN DEFECIENCY TEST

Name:

Birth of date: Month / Day / Year

Email:

Contact No.:

Skype No.:

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Signs and symtoms


1. I look older than I am

Never Sometimes Regular Often Constantly


2. I have trouble falling asleep at night

Never Sometimes Regular Often Constantly


3. I wake up during the night

Never Sometimes Regular Often Constantly


4. And I can't get back to sleep

Never Sometimes Regular Often Constantly


5. My mind is busy with anxious thoughts while I'm trying to fall asleep

Never Sometimes Regular Often Constantly


6. My feet are too hot at night

Never Sometimes Regular Often Constantly


7. When I get up I don't feel rested

Never Sometimes Regular Often Constantly


8. I feel like I'm living of sync with the world going to bed late and waking up late

Never Sometimes Regular Often Constantly


9. I can't tolerate jet lag

Never Sometimes Regular Often Constantly


10. I smoke, drink and/or abuse a betablocker or a sleep aid

Never Sometimes Regular Often Constantly