Sleep Quality Questionnaire

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. Please answer all questions.

    1.During the past month, when 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, when 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 spend in bed.)

    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
    Not during the past month Less than once a week Once or twice a week Three or more times a week
    b. wake up in the middle of the night or early morning
    Not during the past month Less than once a week Once or twice a week Three or more times a week
    c. have to get up to use the bathroom
    Not during the past month Less than once a week Once or twice a week Three or more times a week
    d. cannot breathe comfortably
    Not during the past month Less than once a week Once or twice a week Three or more times a week
    e. cough or snore loudly
    Not during the past month Less than once a week Once or twice a week Three or more times a week
    f. feel too cold
    Not during the past month Less than once a week Once or twice a week Three or more times a week
    g. feel too hot
    Not during the past month Less than once a week Once or twice a week Three or more times a week
    h. have bad dreams
    Not during the past month Less than once a week Once or twice a week Three or more times a week
    i. have pain
    Not during the past month Less than once a week Once or twice a week Three or more times a week
    j. other reason(s), please describe:

    How often during the past month have you had trouble sleeping because of this?
    Not during the past month Less than once a week Once or twice a week Three or more times a week
    6. During the past month, how would you rate your sleep quality overall?
    Very good Fairly good Fairly bad Very bad
    7. During the past month, how often have you taken medicine (prescribed or “over the counter”) to help you sleep?
    Not during the past month Less than once a week Once or twice a week Three or more times a week
    8. During the past month, how often have you had trouble staying awake while driving, eating meals, or engaging in social activity?
    Not during the past month Less than once a week Once or twice a week Three or more times a week
    9. During the past month, how much of a problem has it been for you to keep up enthusiasm to get things done?
    No problem at all Only a very slight problem Somewhat of a problem A very big problem
    10. Do you have a bed partner or room mate?
    No bed partner or room mate Partner/room mate in other room Partner in same room, but not same bed Partner in same bed

    If you have a room mate or partner, ask him/her how often in the past month you have had...

    a. loud snoring
    Not during the past month Less than once a week Once or twice a week Three or more times a week
    b. long pauses between breaths while asleep
    Not during the past month Less than once a week Once or twice a week Three or more times a week
    c. legs twitching or jerking while asleep
    Not during the past month Less than once a week Once or twice a week Three or more times a week
    d. episodes of disorientation or confusion during sleep
    Not during the past month Less than once a week Once or twice a week Three or more times a week
    e. other restlessness while you sleep; please describe:
    Not during the past month Less than once a week Once or twice a week Three or more times a week

    Thank you. Finally, please enter your details then click “Submit”.

    First Name:
    Last Name:
    Date of Birth:
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