Name: | ||||
ID#: | Date: | Age: | ||
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. Please answer all questions. | ||||
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INSTRUCTIONS: For each of the remaining questions, check the one best response. Please answer all questions. | ||||
| Not during the past month | Less than once a week | Once or twice a week | Three or more times a week |
(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:
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How often during the past month have you had trouble sleeping because of this? | ||||
Very good | Fairly good | Fairly bad | Very bad | |
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Not during the past month | Less than once a week | Once or twice a week | Three or more times a week | |
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No problem at all | Only a very slight problem | Somewhat of a problem | A very big problem | |
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No bed partner or roommate | Partner/roommate in other room | Partner in same room, but not same bed | Partner in same bed | |
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If you have a roommate or bed partner, ask him/her how often in the past month have you had... | Not during the past month | Less than once a week | Once or twice a week | Three or more times a week |
(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
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