This questionnaire is a scientifically validated tool to assess your overall sleep quality.
INSTRUCTIONS:
The following questions relate to your usual sleep habits during the past month only. Your answers should indicate the most accurate reply for the majority of days and nights in the past month. For questions 1, 3 and 4, please round your answer to the closest 15 minute increment. Please answer all questions.
1. During the past month, what time have you usually gone to bed at night?
2. During the past month, how long (in minutes) has it usually taken you to fall asleep each night?
3. During the past month, what time have you usually gotten up in the morning?
4. During the past month, how many hours of actual sleep did you get at night? (This may be
different than the number of hours you spent in bed.)
INSTRUCTIONS:
For each of the remaining questions, check the one best response. Please answer all questions.
5. During the past month, how often have you had trouble sleeping because you . . .
a) Cannot get to sleep within 30 minutes
b) Wake up in the middle of the night or early morning
c) Have to get up to use the bathroom
d) Cannot breathe comfortably
e) Cough or snore loudly
f) Feel too cold
g) Feel too hot
h) Had bad dreams
i) Have pain
j) Other reason(s), please describe
How often during the past month have you had trouble sleeping because of this?
6. During the past month, how would you rate your sleep quality overall?
7. During the past month, how often have you taken medicine to help you sleep (prescribed or "over the counter")?
8. During the past month, how often have you had trouble staying awake while driving, eating meals, or engaging in social activity?
9. During the past month, how much of a problem has it been for you to keep up enough enthusiasm to get things done?
10. Do you have a bed partner or room mate?
If you have a room mate or bed partner, ask him/her how often in the past month you have had. . .
a) Loud snoring
b) Long pauses between breaths while asleep
c) Legs twitching or jerking while you sleep
d) Episodes of disorientation or confusion during sleep
e) Other restlessness while you sleep; please describe
How often during the past month have you had this type of restlessness?