Insomnia Symptom Questionnaire - uofthenet.org

1 Insomnia Symptom QuestionnaireName:date:Instructions: If you have experienced any sleep symptoms during the past month please circle the appropriate number to let us know how your sleep is affecting your daily the past month did you not knowRarelyless than once per weekSometimes1-2 times per weekFrequently3-4 times per weekAlways5-7 times per weekHow long has the Symptom lasted?(# of weeks, months or years)1. Difficulty falling asleep?0123452. Difficulty staying asleep?0123453. Frequent awakenings from sleep?0123454. Feeling that your sleep is not sound?0123455. Feeling that your sleep is unrefreshing?

2 012345 Instructions: If you have experienced any sleep symptoms during the past month please circle the appropriate number to let us know how your sleep is affecting your daily the past at allA little bitModeratelyQuite a bitExtremely6. How much did your sleep problems bother you?012347. Have your sleep difficulties affected your work?012348. Have your sleep difficulties affected your social life?012349. Have your sleep difficulties affected other important parts of your life?0123410. Have your sleep difficulties made you feel irritable?0123411. Have your sleep difficulties caused you to have trouble concentrating?

3 0123412. Have your sleep difficulties made you feel fatigued?0123413. How sleepy do you feel during the day?01234