Shift Worker Sleep Reset • Intake Form

Shift Worker Sleep Reset — Intake

Please complete before your first session. You can download a PDF of your responses and email it to info@yoursleepclinic.com. This programme uses CBT‑I strategies adapted for shift work.

1) Your Details

Full name

Date of birth

Phone

Occupation / role

Employer / organisation

Consent

I consent to coaching, understand this is not medical care, and agree to data being used to deliver services and communicate with me.

2) Work Pattern

Shift type

Describe your usual shift pattern (start/finish times, cycle)

How long have you been working shifts?

Max consecutive nights worked

Days off between rotations

Commute length (minutes)

3) Sleep Challenges

What are your main difficulties? (e.g., sleeping in the day, staying awake on nights, switching between shifts)

How well do you feel you adapt to shift changes? (0–10)

Difficulty staying alert at work (0–10)

Any safety incidents or near misses due to fatigue?

4) Sleep Snapshot (past 2 weeks)

Main sleep (usual clock time)

How long to fall asleep (minutes)

Total time awake during sleep period (minutes)

Estimated total sleep time (hours)

Naps (frequency, timing, duration)

5) Health & Lifestyle

Medical conditions

Medications & supplements

Caffeine use (type & amount per 24h)

Alcohol use (units/week)

Nicotine or vaping

Exercise (type & weekly minutes)

6) Environment & Coping

Daytime sleep environment (darkness, noise, temperature)

Coping aids (blackout blinds, earplugs, light box, caffeine naps, melatonin)

Family or social responsibilities that affect sleep

7) Readiness & Goals

Top 3 goals for this programme

How much do you worry about sleep? (0–10)

Motivation to follow the plan (0–10)

Submission & Download

When finished, click “Download my completed form (PDF)”. Then attach it to an email to info@yoursleepclinic.com.

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