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睡眠问卷

Sleep Quality Survey 睡眠品质调查问卷

Sleep Well, Live Well

步骤 1 字，最多 2

50%

您的个人资料 YOUR DETAILS:
您的名字 Your Name:*
Name
您的手机号码 Your Contact No:*
您的电邮 Your Email:*
请问是谁邀请你做这调查问卷？Who invited you to do this Survey?*
😴【睡眠质量】首先，圈出每个问题的最准确答案。最后，将所有分数加起来，以获得睡眠评估以及改善技巧。
😴 [Sleep Quality Survey] First, select the most accurate answer to each question. Finally, add up your scores to get a sleep assessment and improvement skills.
1.您需要多长时间才能入睡？How long it takes for you to fall asleep?*
- 0-15 minutes (4 points)
- 16-30 minutes (3 points)
- 31–45 minutes (2 points)
- 46–60 minutes (1 point)
- >60 minutes (0 point)
2.如果您睡后，会再醒来一次或多次，那么您总共醒了多长时间？将您睡后再醒来的清醒的所有时间加起来。If you wake up one or more times after sleeping, how long have you been awake in total? Add up all the awake time you wake up after sleeping.*
- 0-15 minutes (4 points)
- 16-30 minutes (3 points)
- 31–45 minutes (2 points)
- 46–60 minutes (1 point)
- >60 minutes (0 point)
3. 如果您的最终睡醒时间是在您打算睡醒之前发生的（提早睡醒），那么这是要早醒多少时间？If your final wake-up time occurs before you intend to wake up (waking up early), how much time do you have to wake up early?*
- 我醒得不会太早醒，最多15分钟（4 points)
- 16-30分钟 (3 points)
- 31-45分钟前 (2 points)
- 46-60分钟 (1 point)
- > 60分钟 (0 point)
4. 您每周有几个晚上会有睡眠问题？How many nights a week do you have sleep problems?*
- 0–1次 time (4 points）
- 2次 times (3 point)
- 3次 times (2 point)
- 4次 times (1 point)
- 5–7次 times (0 point)
5. 您如何评价自己的睡眠质量？ How would you rate your quality of sleep?*
- 很好 / Very Good (4 points)
- 好 / Good (3 points)
- 一般 / OK (2 points)
- 差 / Poor (1 point)
- 很差 / Very Poor (0 point)
6. 想一想过去的一个月，睡眠差到什么程度.. 影响了您的情绪，精力或人际关系？Think about how poor your sleep was in the past month... Has it affected your mood, energy or relationships?*
- 没有影响 Not affected (4 points)
- 有一点点影响 A little bit affected (3 points)
- 有影响 Affected (2 points)
- 很有影响 Very affected (1 point)
- 影响非常大 Badly affected (0 point)
7. 睡眠问题影响了您的注意力，生产力或保持清醒的能力？ Has sleep problems affected your concentration, productivity, or ability to stay awake?*
- 没有影响 Not affected (4 points)
- 有一点点影响 A little bit affected (3 points)
- 有影响 Affected (2 points)
- 很有影响 Very affected (1 point)
- 影响非常大 Badly affected (0 point)
8. 总的来说，以上的问题会困扰你吗？ In general, will the above problems bother you?*
- 没有影响 Not affected (4 points)
- 有一点点影响 A little bit affected (3 points)
- 有影响 Affected (2 points)
- 很有影响 Very affected (1 point)
- 影响非常大 Badly affected (0 point)
9. 您的睡眠问题多久了？ How long have you had sleep problems?*
- 我没问题/ 少过1个月 Less than 1 month (4 points)
- 1-2个月 month (3 points)
- 3–6个月 month (2 points)
- 7–12个月 month (1 point)
- > 1年 year (0 point)
您的总分 Your total points:
您的分数结果是 Your score result is :
0–9 points : 您的睡眠问题似乎很严重。您绝对应该尝试获得一些帮助。Your sleep problems seem to be severe. You should definitely try to get some help.
您的分数结果是 Your score result is :
10–18 points : 您有一些睡眠问题。重要的是要检查您的睡眠习惯，并了解如何进行更改。You have some sleep problems. It’s important to examine your sleep habits and see how you can make changes.
您的分数结果是 Your score result is :
19–27 points : 您的睡眠状况良好，但是您仍然可以采取许多步骤来改善睡眠质量。Your sleep is in good shape, but there are still many steps you can take to make it even better.
您的分数结果是 Your score result is :
28–36 points : 您的睡眠状况良好。继续做自己在做的事情！Your sleep is in great shape. Keep doing what you’re doing and spread the word!

【舒眠精油问卷】Feedbacks on Sleep Well Essential Oil
1) 您尝试的是哪一款加油? (一款精油一份调查) Which formula you tried? (one formula one survey)*
- Good Night Blend 晚安舒眠
- Lavender 薰衣草
- Clary Sage 鼠尾香
- Frankincense 乳香
- Geranium 天竺葵
- Patchouli 广香
- Peppermint 薄荷
- Ylang Ylang 依兰
- 其它 Others
其它 Others*
2) 你如何使用？How do you use it?*
- 放进香芬器 Diffuser / Nebulizer
- 滴在枕头 Drop on pillow
- 稀释后擦在脸、颈、身上 Put on the face & body after dilution
- 其它 Others
其它 Others*
3) 你每次使用多少滴？How many drops you put each time?*
4) 你每次使用多久时间？How long you use each time?*
- 1 hour
- 2 hour
- 3 hour
- 4 hour
- 5 hour
- 6 hour
- 7 hour
- 8 hour
5) 你尝试了这款精油多少天？ How many days have you tried?*
6) 精油的味道 The smell of the E.O.*
- 很喜欢 Like it so much
- 喜欢 Like it
- 还好，可以接受 Ok can accept
- 不喜欢 Don't like it
- 很不喜欢 Very dislike it
7) 这款精油可以帮助你（可选择多项）This essential oil can help you (can choose multiple answers):*
- 静心 calm
- 安神 quiet down the mind
- 舒服 comfortable
- 放松 relax
- 安全感 sense of security
- 入眠 help me sleep
8) 总结一下你对这款精油的感觉和评价 Summarise your feelings and comments on this essential oil:*

Senses World Sdn Bhd

Registration No: 202001023959 (1380279-U)

Address: No 2-3, Jalan PJS11/28A, 46150 Bandar Sunway, Selangor. Malaysia
Contact: 03-5613 1931
Email: info@mysensesworld.com

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