Sleep Quality

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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.

USUAL BED TIME
NUMBER OF MINUTES
USUAL GETTING UP TIME
HOURS OF SLEEP PER NIGHT

INSTRUCTIONS

For each of the remaining questions, check the one best response. Please answer all questions.

During the past month, how often have you had trouble sleeping because you ...
... cannot get to sleep within 30 minutes*
... wake up in the middle of the night or early morning*
... have to get up to use the bathroom*
... cannot breathe comfortably*
... cough or snore loudly*
... feel too cold*
... feel too hot*
... had bad dreams*
... have pain*
During the past month, how often have you taken medicine (prescribed or "over the counter") to help you sleep?*
During the past month, how often have you had trouble staying awake while driving, eating meals, or engaging in social activity?*
During the past month, how much of a problem has it been for you to keep up enough enthusiasm to get things done?*
During the past month, how would you rate your sleep quality overall?*

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