Are you sleeping well?
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Question 1
Please rate the current (i.e., last 2 weeks) SEVERITY of your insomnia problem(s).
0 None
1 Mild
2 Moderate
3 Severe
4 Very
| 0 | 1 | 2 | 3 | 4 | |
|---|---|---|---|---|---|
(a) Difficulty falling asleep |
0 None | 1 Mild | 2 Moderate | 3 Severe | 4 Very |
(b) Difficulty staying asleep |
0 None | 1 Mild | 2 Moderate | 3 Severe | 4 Very |
(c) Problem waking up to early |
0 None | 1 Mild | 2 Moderate | 3 Severe | 4 Very |
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Question 2
How SATISFIED/dissatisfied are you with your current sleep pattern?
| 0 Very Satisfied | 1 Satisfied | 2 Moderately Satisfied | 3 Dissatisfied | 4 Very Dissatisfied |
|---|---|---|---|---|
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Question 3
To what extent do you consider your sleep problem to INTERFERE with your daily functioning (e.g. daytime fatigue, ability to function at work/daily chores, concentration, memory, mood, etc.).
| 0 Not at all Interfering | 1 A Little | 2 Somewhat | 3 Much | 4 Very Much Interfering |
|---|---|---|---|---|
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Question 4
How NOTICEABLE to others do you think your sleeping problem is in terms of impairing the quality of your life?
| 0 Not at all Noticeable | 1 Barely | 2 Somewhat | 3 Much | 4 Very Much Noticeable |
|---|---|---|---|---|
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Question 5
How WORRIED/distressed are you about your current sleep problem?
| 0 Not at all | 1 A Little | 2 Somewhat | 3 Much | 4 Very Much |
|---|---|---|---|---|
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