1 – Not at all
2 – A little bit
3 – Somewhat
4 – Quite a bit
5 – Very much
¹
1
2
3
4
5
1
In the past 7 days...
I had a hard time getting things done because I was sleepy.
2
I felt alert when I woke up.
3
I felt tired.
4
I had problems during the day because of poor sleep.
5
I had a hard time concentrating because of poor sleep.
6
I felt irritable because of poor sleep.
7
I was sleepy during the daytime.
8
I had trouble staying awake during the day.
The presented answer sheet is not an original form and is not intended for printing or use as a handout.
The answer numbers are used only to label response columns. They are NOT scores and should not be used for calculating results.