Psychological Sleep Services Sleep Assessment Name Date **************************************************** Insomnia Severity Index For each question, please CIRCLE the number that best describes your answer. Please rate the CURRENT (i.e. LAST 2 WEEKS) SEVERITY of your insomnia problem(s). Insomnia problem None Mild Moderate Severe Very severe 1. Difficulty falling asleep 0 1 2 3 4 2. Difficulty staying asleep 0 1 2 3 4 3. Problem waking up too early 0 1 2 3 4 4. How SATISFIED/DISSATISFIED are you with your CURRENT sleep pattern? Very Satisfied Moderately Dissatisfied Very Satisfied Satisfied Dissatisfied 0 1 2 3 4 5. How NOTICEABLE to others do you think your sleep problem is in terms of impairing the quality of your life? Not at all A Little Somewhat Much Very Much Noticeable Noticeable 0 1 2 3 4 6. How WORRIED/DISTRESSED are you about your current sleep problem? Not at all A Little Somewhat Much Very Much Worried Worried 0 1 2 3 4 7. 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 A Little Somewhat Much Very Much Interfering Interfering 0 1 2 3 4
THE EPWORTH SLEEPINESS SCALE Name: Today s Date: How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? This refers to your usual way of life in the past week. Even if you have not done some of these things recently try to work out how they would have affected you. Use the following scale to choose the most appropriate number for each situation: 0 = would never doze 1 = slight chance of dozing 2 = moderate chance of dozing 3 = high chance of dozing Situation Chance of Dozing Sitting and reading Watching TV Sitting, inactive in a public place (e.g. a theater or a meeting) As a passenger in a car for an hour without a break Lying down to rest in the afternoon when circumstances permit Sitting and talking to someone Sitting quietly after a lunch without alcohol In a car, while stopped for a few minutes in the traffic
Beliefs About Sleep Several statements reflecting people s beliefs and attitudes about sleep are listed below. Please indicate (by circling the number) to what extent you personally agree or disagree with each statement. There is no right or wrong answer. For each statement, circle a number that best reflects your personal experience. Consider the whole scale, rather than only the extremes of the continuum. 1. I need 8 hours of sleep to feel refreshed and function well during the day. 2. When I do not get proper amount of sleep on a given night, I need to catch up on the next day by napping or on the next night by sleeping longer. 3. I am concerned that chronic insomnia may have serious consequences for my physical health. 4. I am worried that I may lose control over my abilities to sleep. 5. After a poor night s sleep, I know that it will interfere with my daily activities on the next day. 6. In order to be alert and function well during the day, I am better off taking a sleeping pill rather than having a poor night s sleep. 7. When I feel irritable, depressed, or anxious during the day, it is mostly because I did not sleep well the night before. 8. When I sleep poorly on one night, I know that it will disturb my sleep schedule for the whole week. 9. Without an adequate night s sleep, I can hardly function the next day. 10. I can t ever predict whether I will have a good or poor night s sleep. 11. I have little ability to manage the negative consequences of disturbed sleep. 12. When I feel tired, have no energy, or just seem not to function well during the day, it is generally because I did not sleep well the night before. 13. I believe that insomnia is essentially a result of a chemical imbalance. 14. I feel that insomnia is ruining my ability to enjoy life and prevents me from doing what I want. 15. Medication is probably the only solution to sleeplessness. 16. I avoid or cancel obligations (social, family, occupational) after a poor night s sleep.
Morningness/Eveningness Directions: For each item, please check one response that best describes you. 1. Considering only your own feeling best rhythm, at what time would you get up if you were entirely free to plan your day? a.(5) 5:00-6:30 a.m. b.(4) 6:30-7:45 a.m. c.(3) 7:45 9:45 a.m. d.(2) 9:45-11:00 a.m. e.(1) 11:00 a.m. 12:00 noon 2. Considering only your own feeling best rhythm, at what time would you go to bed if you were entirely free to plan your evening? a.(5) 8:00-9:00 p.m. b.(4) 9:00-10:15 p.m. c.(3) 10:15 p.m.- 12:30 a.m. d.(2) 12:30-1:45 a.m. e.(1) 1:45 a.m. 3:00 a.m. 3. Assuming normal circumstances, how easy do you find getting up in the morning? a.(1) Not at all easy b.(2) Slightly easy c.(3) Fairly easy d.(4) Very easy a.(5) 8:00-9:00 p.m. b.(4) 9:00-10:15 p.m. c.(3) 10:15 p.m. 12:30 a.m. d.(2) 12:30-1:45 a.m. e.(1) 1:45 a.m. 3:00 a.m. 8. You wish to be at your peak performance for a test, which you know is going to be mentally exhausting and lasting for two hours. You are entirely free to plan your day, and considering only your own feeling best rhythm, which ONE of the four testing times would you choose? a.(4) 8:00-10:00 a.m. b.(3) 11:00 a.m. - 1:00 p.m. c.(2) 3:00-5:00 p.m. d.(1) 7:00-9:00 p.m. 9. One hears about morning and evening type people. Which ONE of these types do you consider yourself to be? a.(4) Definitely a morning type b.(3) More a morning than an evening type c.(2) More an evening than a morning type d.(1) Definitely an evening type 4. How alert do you feel after the first half hour after having awakened in the morning? a.(1) Not at all alert b.(2) Slightly alert c.(3) Fairly alert d.(4) Very alert 5. During the first half hour after having awakened in the morning, how tired do you feel? a.(1) Very tired b.(2) Fairly tired c.(3) Slightly tired d.(4) Not at all tired 6. You have decided to engage in some physical exercise. A friend suggests that you do this one hour twice a week and the best time for him is 7:00-8:00 am. Bearing in mind nothing else but your feeling best rhythm, how do you think you would perform? a.(4) Would be in good form b.(3) Would be in reasonable form c.(2) Would find it difficult d.(1) Would find it very difficult 7. At what time in the evening do you feel tired and as a result, in need of sleep? 10. When would you prefer to rise (provided you have a full day s work 8 hours) if you were totally free to arrange your time? a.(4) Before 6:30 a.m. b.(3) 6:30 7:30 a.m. c.(2) 7:30-8:30 a.m. d.(1) 8:30 a.m. or later 11. If you always had to rise at 6:00 am, what do you think it would be like? a.(1) Very difficult and unpleasant b.(2) Rather difficult and unpleasant c.(3) A little unpleasant but no great problem d.(4) Easy and not unpleasant 12. How long a time does it usually take before you recover your senses in the morning after rising from a night s sleep? a.(4) 0-10 minutes b.(3) 11-20 minutes c.(2) 21-40 minutes d.(1) More than 40 minutes 13. Please indicate to what extent you are a morning or an evening active individual? a.(4) Very morning active (morning alert & evening tired) b.(3) To some extent, morning active c.(2) To some extent, evening active d.(1) Very evening active (morning tired & evening alert)
Sleep-Related Behaviours Questionnaire Please carefully read each of the statements below and circle the number that best describes how often you do the following things in order to cope with tiredness or improve your sleep. To cope with tiredness or improve sleep... Never/Almost Rarely Sometimes Often Always/Almost 1. I spend time considering ways to improve sleep 0 1 2 3 4 2. I stay in the background in social situations 0 1 2 3 4 3. I try to stop all thinking when trying to get to sleep 0 1 2 3 4 4. I do something active close to bedtime to tire myself out 0 1 2 3 4 5. I miss or cancel appointments (daytime or evening) 0 1 2 3 4 6. During the day, I block thoughts about sleep out of my mind 0 1 2 3 4 7. I reduce my expectations of what I can achieve 0 1 2 3 4 8. I figure out how I will catch up on my sleep later on 0 1 2 3 4 9. I work hard to conserve energy 0 1 2 3 4 10. I try to keep all disturbing thoughts and images out of my mind while in bed 0 1 2 3 4 11. I avoid talking about my sleep 0 1 2 3 4 12. I look at the clock on waking to calculate how many hours of sleep I got 0 1 2 3 4 13. I plan to get an early night 0 1 2 3 4 14. I give up trying to work 0 1 2 3 4 15. I take a sleeping pill or pills 0 1 2 3 4 16. I catch up on sleep by napping 0 1 2 3 4 17. I wear earplugs to block out all sounds that might wake me up/prevent me falling asleep 0 1 2 3 4 18. I worry about the consequences of poor sleep while lying in bed 0 1 2 3 4 19. I take on fewer social commitments 0 1 2 3 4 20. I put off tasks until tomorrow 0 1 2 3 4 21. I avoid difficult conversations with people 0 1 2 3 4 22. During the day, I conserve energy any way I can 0 1 2 3 4 23. I avoid sleeping away from home 0 1 2 3 4 24. I look at the clock to see how long it's taking to get to sleep 0 1 2 3 4 25. I am less active during the day 0 1 2 3 4 26. I keep busy to stop thinking about my sleep 0 1 2 3 4 27. I limit myself to mundane chores or tasks during the day/evening 0 1 2 3 4 28. I worry about other things (e.g., work) to distract from concerns about sleep 0 1 2 3 4 29. I take herbal remedies to aid sleep 0 1 2 3 4 30. While in bed, I try to block out thinking about any problems 0 1 2 3 4 31. I stick to a routine during the day so that I don't have to think as much 0 1 2 3 4 32. I give myself lots of time to fall asleep by going to bed early. 0 1 2 3 4
SLEEP ENVIRONMENT QUESTIONNAIRE 1. I use an alarm clock five or more days a week. 2. I keep the temperature in the bedroom so cold that I have 2 or more blankets on the bed to stay warm at night 3. The blinds and curtains in the bedroom are so effective that at sunrise the room is so dark its hard to tell that the sun came up. 4. I have spent real time and money making sure that my mattress and pillow are perfect for me. 5. During the night, my bedroom is insulated so well that I rarely if ever hear outside noise from the road, neighbors, etc. 6. House noise from the radiators, floor boards, etc. is so minimal that I am rarely aware of such sounds. 7. My home is a safe place. My partner and/or pet insure and/or the locks and alarm system and/or concern and support of my neighbors provide me a level of comfort such that I rarely if ever worry about being safe at night. 8. On three or more nights per week, I engage in two or more of the following behaviors in the bedroom: watch TV, read, plan, worry, work, clean, or eat). 9. My pets rarely if ever keep me from falling asleep or wake me up during the night. 10. My bed partner s sleep schedule or habits while in bed (reading, moving about, stealing the covers, snoring, etc.) rarely if ever disturb my sleep. 11. My child s/children s sleep schedule or habits while in bed or during the night rarely if ever disturb my sleep.
Glasgow Sleep Effort Scale Broomfield, N., & Espie, C. (2005). Towards a valid, reliable measure of sleep effort. Journal of Sleep Research, 14, 401-407. The following seven statements relate to your night-time sleep pattern in the past week. Please indicate by circling one response how true each statement is for you. 1 I put too much effort into sleeping when it should come naturally Very much To some extent Not at all 2 I feel I should be able to control my sleep Very much To some extent Not at all 3 I put off going to bed at night for fear of not being able to sleep Very much To some extent Not at all 4 I worry about not sleeping if I cannot sleep Very much To some extent Not at all 5 I am no good at sleeping Very much To some extent Not at all 6 I get anxious about sleeping before I go to bed Very much To some extent Not at all 7 I worry about the consequences of not sleeping Very much To some extent Not at all
Generalized Anxiety Disorder 7- item (GAD- 7) scale Over the last 2 weeks, how often have you been bothered by the following problems? Not at all sure Several days Over half the days Nearly every day 1. Feeling nervous, anxious or on edge 0 1 2 3 2. Not being able to stop or control worrying 3. Worrying too much about different things 0 1 2 3 0 1 2 3 4. Trouble relaxing 0 1 2 3 5. Being so restless that it is hard to sit still 0 1 2 3 6. Becoming easily annoyed or irritable 0 1 2 3 7. Feeling afraid as if something awful might happen Column total Overall total 0 1 2 3 If you checked off any problems, how difficult have these made it for you to do your work, take care of things at home, or get along with other people? Not difficult at all Somewhat difficult Very difficult Extremely difficult Developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues, with an educational grant from Pfizer Inc. No permission required to reproduce, translate, display or distribute.