Insomnia Questionnaire

Insomnia

How long does it take you to fall asleep at night?
Fall asleep right away
½ hour
1 hour
2 hours
3 or more hours
How often do you wake up in the middle of the night?
Never
1 time
2 times
3 or more times
How long does it take you to fall back asleep when you wake up in the middle of the night?
Never wake up in the middle of the night
½ hour
1 hour
2 or more hours
Do you wake up very early in the morning and find it hard to get back to sleep?
Yes No
After a full night of sleep, do you feel well rested?
Usually
Sometimes
Never
Do you often feel sleepy in the daytime?
Always
Sometimes
Never
Do you feel down, depressed, or under a lot of pressure?
Yes No
Do you sleep for less than 5 hours a night?
Yes No
Do you sleep for more than 9 hours a night?
Yes No
On the weekends, what time do you go to bed?
8 to 10 p.m.
10 p.m. to Midnight
Midnight to 2 a.m.
2 to 4 a.m.
After 4 a.m.
On the weekends, what time do you get up in the morning?
5 to 7 a.m.
7 to 9 a.m.
9 to 11 a.m.
11 a.m. to 1 p.m.
1 to 3 p.m.
Later than 3 p.m.
Are you interested in finding out about how to sleep better?
Yes No