This test is designed to help you determine whether you have a circadian rhythm disorder, the severity of the disorder, and customize a schedule to shift your circadian rhythm back to its normal pattern.

You may feel that some questions have more than one acceptable answer. Please choose the answer that is closest to your situation.

1. Enter the name of the person taking the assessment:
   
   
2. Circadian Rythm Disorders differ according to age and sex. Please specify:
   Age:         Sex: Female     Male
   

3. At what time of day do you feel most energetic?
   

   	Morning		Evening
   	Mid-morning		Night
   	Afternoon		Late night (after midnight)
   	Late afternoon		My energy level stays about the same during the day.
   			I lack energy or feel down most of the day.

   
   
4. At what time of day do you feel down or tired? (Check all that apply)
   

   	Morning		Evening
   	Mid-morning		Night
   	Afternoon		Late night (after midnight)
   	Late afternoon		I feel tired most of the time.
   			I don't notice any specific time.

   
   
5. Choose the answer that best describes your sleep and mood.
   

   How I sleep (nighttime):	My energy/mood (daytime):
   I get enough sleep I don't get enough sleep I oversleep	I feel fine during the day I feel tired or down at some point during the day

6. What time do you usually fall asleep?
   

   	Before 8 pm		Before 12 am
   	Before 9 pm		After midnight
   	Before 10 pm		Rarely fall asleep
   	Before 11 pm

   
   
7. How long do you usually lie awake before falling asleep?
   

   	Fall asleep quickly		less than 3 hrs.
   	30 min.		less than 4 hrs.
   	less than 1 hr.		4 hrs. or more
   	less than 2 hrs.		Rarely fall asleep

   
   
8. When you go to bed at your usual time, what time does your body wake up naturally? Assume that you don't use your alarm clock and you are free from work, school, or other commitments.
   

   	2 am or earlier		10 am
   	3 am		11 am
   	4 am		12 pm
   	5 am		1 pm
   	6 am		2 pm
   	7 am		3 pm
   	8 am		4 pm or later
   	9 am

   
   
9. What time do you need to get up each morning?
   

   	5 am or earlier		8 am
   	5:30 am		8:30 am
   	6 am		9 am
   	6:30 am		9:30 am
   	7 am		10 am
   	7:30 am		10:30 am or later

   
   
10. Describe how you sleep. (Assume you need to wake up at a certain time each morning.)
    

    How I fall asleep:	My ability to stay asleep at night:
    Easily Fairly easily A little difficult Difficult Very difficult	Usually stay asleep Wake up but fall asleep again easily Wake up but difficult to fall sleep again Difficulty staying asleep
    How my body naturally wakes up: Much earlier than I'm supposed to Earlier than I'm supposed to Without problems I need the alarm to wake me up I still sleep in after the alarm Very difficult to get up Usually before the alarm, but sometimes I sleep in

    
    
11. At what time of year do you notice sleep, energy or mood problems?
    

    Begins:		Ends:
    	Early Fall (Aug/Sep)		Early Fall (Aug/Sep)
    	Late Fall (Oct/Nov)		Late Fall (Oct/Nov)
    	Winter (Dec/Jan)		Winter (Dec/Jan)
    	Late Winter (Feb)		Late Winter (Feb)
    	Early Spring (Mar/Apr)		Early Spring (Mar/Apr)
    	Spring/Summer (May/Jun)		Spring/Summer (May/Jun)
    	Summer (Jul/Aug)		Summer (Jul/Aug)
    	My problem(s) are about the same all year round.
    	I don't notice problems at any time during the year.