Questions | Rating Category | ||||
---|---|---|---|---|---|
1. Please rate the current (i.e., last 2 weeks) severity of your insomnia problem(s). | None | Mild | Moderate | Severe | Very Severe |
Difficulty falling asleep | 0 | 1 | 2 | 3 | 4 |
Difficulty staying asleep | 0 | 1 | 2 | 3 | 4 |
Problem waking up too early | 0 | 1 | 2 | 3 | 4 |
2. How satisfied/dissatisfied are you with your current sleep pattern? | Very Satisfied | Satisfied | Neutral | Dissatisfied | Very Dissatisfied |
0 | 1 | 2 | 3 | 4 | |
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.)? | Not At All Interfering | A Little | Somewhat | Much | Very Much Interfering |
0 | 1 | 2 | 3 | 4 | |
4. How noticeable to others do you think your sleeping problem is in terms of impairing the quality of your life? | Not At All Noticeable | A Little | Somewhat | Much | Very Much Noticeable |
0 | 1 | 2 | 3 | 4 | |
5. How worried/distressed are you about your current sleep problem? | Not At All Worried | A Little | Somewhat | Much | Very Much Worried |
0 | 1 | 2 | 3 | 4 |
Adapted with permission from Ref. 41.