Section 1

Basic Information

• Full Name*
• Email*
• Phone

Section 2

About Sleep

Section 2A

Sleep: Onset, Duration & Continuation

• I fall asleep immediately after going to bed (Less than 15 minutes)NeverRarelySometimesUsuallyAlways
• I have enough hours of sleep during night (6 to 8 hours /night)NeverRarelySometimesUsuallyAlways
• I keep getting awake during night or in middle of sleep (More than two times)NeverRarelySometimesUsuallyAlways

Section 2B

Sleep satisfaction & Physical, Intellectual & emotional effects of Sleep Deprivation

• I have satisfactory sleep during night & feel fresh after getting upNeverRarelySometimesUsuallyAlways
• I feel tired & exhausted during dayNeverRarelySometimesUsuallyAlways
• I can’t concentrate & focus on routines NeverRarelySometimesUsuallyAlways
• My overall work performance reduces NeverRarelySometimesUsuallyAlways
• I feel Irritable during daytimeNeverRarelySometimesUsuallyAlways
• I feel depressed /tired/gloomy during daytimeNeverRarelySometimesUsuallyAlways

Section 2C

Dreams & its effects on sleep

• I don’t have or can’t remember dreamsNeverRarelySometimesUsuallyAlways
• I have a sleep with dreams which are Non disturbing /Dreams of routine activitiesNeverRarelySometimesUsuallyAlways
• I have a sleep with dreams which are Repetitive/disturbing/Scary /Negative/too many thoughts/activitiesNeverRarelySometimesUsuallyAlways
• I have a sleep with dreams which are Somnambulistic/Shouting & startling in dream/Nightmares/Disturbs sleep & post sleep freshnessNeverRarelySometimesUsuallyAlways

Section 3

• Description of Changes on Sleep & Overall experience:
  
• Description of Dreams you have seen:
  
• Description of Emotions & Images you have experienced while listening:
  
• Description of any other Physical or psychological changes during these 15days:
  
• Overall experience:
  

• Terms & Conditions
  1. Research participation for music therapy is my choice . For any unforeseen circumstances, the doctors are not responsible.
  2. We do not recommend to discontinue any other treatment or medicines the participant is already taking.The research participant should not discontinue any other mode of treatment without the consent of the treating the consultant physician.

• I agree to terms & conditions

• I would like to volunteer for music therapy research