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

During the past month have you had any of the following problems with your work or
other regular daily activities as a result of your physical health? Please tick the
appropriate box.
13. Cut down on the amount of time you spent on work or
other activities
16. Accomplished less than you would like
17. Were limited in the kind of work or other activities?
16. Had difficulty performing the work or other activities for
example it took extra effort
Yes No
1 2
1 2
1 2
1 2
During the past month have you had any of the following problems with your work to
other regular activities as a result of any emotional problems e.g. feeling depressed or
anxious? Please tick the appropriate box.
17. Cut down on the amount of time you spent on work or
other activities
18. Accomplished less than you would like
19. Didn‟t do work or other activities as carefully as usual
20. During the past month to
what extent has your physical
health or emotional problems
interfere with your normal
social activities with family,
friends, neighbours or groups
21. How much physical pain
have you had in the past
month
22. During the past month how
much did pain interfere with
your normal work (both paid
and/or housework)
Yes No
1 2
Not at all Slightly Moderately quite a
bit
None Very
mild
Not at all A little
bit
1 2
1 2
Extremely
Mild Moderate Severe Very
Severe
Moderately Quite
a bit
Extremely
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