1. Please rate the current (i.e. last two weeks) severety of your insomnia problems:Difficulty falling asleep.
None
Mild
Moderate
Severe
Very Severe
2. Please rate the current (i.e. last two weeks) severety of your insomnia problems:Difficulty staying asleep.
None
Mild
Moderate
Severe
Very Severe
3. Please rate the current (i.e. last two weeks) severety of your insomnia problems:Problems waking up too early.
None
Mild
Moderate
Severe
Very Severe
4. How satisfied/dissatisfied are you with your current sleep pattern?
Very Satisfied
Satisfied
Moderately Satisfied
Dissatisfied
Very Dissatisfied
5. To what extent do you consider your sleep problem to interfere with your daily functioning (e.g. daytime fatigue, mood, ability to function at work/daily chores, concentration, memory, mood, etc.) currently?
Not at all Interfering
A Little
Somewhat
Much
Very Much Interfering
6. How noticeable to others do you think your sleep problem is in terms of impairing the quality of your life?
Not at all Noticeable
A Little
Somewhat
Much
Very Much Noticeable
7. How worried/distressed are you about your current sleep problem?