Sick and Tired: Understanding and Managing Sleep Difficulties in ...

The following questions relate to your usual sleeping habits. Please indicate, how often
have you have experienced the situations listed below by ticking the box that
represents how often this has occurred in the past month.
1. Cannot get to sleep within 30
minutes
2. Wake up in the middle of the
night or early morning
3. Have to get up to use the
bathroom
4. Cannot breathe comfortably
5. Cough or snore loudly
6. Feel too cold
7. Feel too hot
8. Have bad dreams
9. Have pain
10. Other reason(s) please describe
including how often you have had
trouble sleeping because of this
reason:
11. During the past month how
often have you taken medicine
(prescribed or over the counter) to
help you sleep?
12. During the past month how
often have you had trouble staying
awake while driving, eating meals or
engaging in social activity
13. During the past month how
much of a problem has it been for
you to keep up enthusiasm to get
things done
14. During the past month how
would you rate your sleep quality
overall
Not during
the past
month
Less than
once a
week
Once or
twice a
week
Three or
more
times a
week
0 1 2 3
0 1 2 3
0 1 2 3
0 1 2 3
0 1 2 3
0 1 2 3
0 1 2 3
0 1 2 3
0 1 2 3
0 1 2 3
0 1 2 3
0 1 2 3
0 1 2 3
Very Good Fairly good Fairly bad Very bad
0 1 2 3
192