Weekly Sleep Diary Name Instructions: Keep this at your bedside and complete each morning upon awakening. Day of the week Calendar date Yesterday, I napped for: (add total naps, eg., 15 mins, ½, 1, 2 hrs, etc) Yesterday, I drank cups of (caffeine) at (time). Last night I took mg of or of alcohol as a sleep aid. (Include prescription, herbal, and overthe-counter sleep aids). Last night I went to bed at: Last night I turned out the lights to go to sleep at: It took about minutes to fall asleep. (SOL) Last night I woke up times. I was awake minutes (total time of all awakenings). (WASO) I woke up at this morning. I got out of bed for the day at: I would rate the quality of my sleep: Very poor Fair Excellent 1 2 3 4 5 6 7 8 9 10 Total Sleep Time (TST) Time in Bed (TIB) Sleep Efficiency (SE)
Insomnia Severity Index Name For each question, please CIRCLE the number that best describes your answer. 1-3. 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 2. Difficulty staying asleep 3. Problem waking up too early 4. How SATISFIED/DISSATISFIED are you with your CURRENT sleep pattern? Very Satisfied Satisfied Moderately Dissatisfied Very Satisfied Dissatisfied 5. How NOTICEABLE to others do you think your sleep problem is in terms of impairing the quality of your life? Noticeable Noticeable 6. How WORRIED/DISTRESSED are you about your current sleep problem? Worried Worried 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? Interfering Interfering Guidelines for Scoring/Interpretation: Add the scores for all seven items (questions 1 + 2 + 3 + 4 + 5 +6 + 7) = your total score Total score categories: 0 7 = No clinically significant insomnia 8 14 = Subthreshold insomnia 15 21 = Clinical insomnia (moderate severity) 22 28 = Clinical insomnia (severe) From Charles M. Morin, Ph.D., Université Laval
CBT-I Program Patient Satisfaction Survey We would like to know how you feel about the services we provide so we can make sure we are meeting your needs. Your responses are directly responsible for improving these services. All responses will be kept confidential and anonymous. Thank you for your time. GREAT GOOD OK FAIR POOR Please circle how well you think we are doing in the following areas: 5 4 3 2 1 Ease of getting care: Ability to get in to the program 5 4 3 2 1 Hours program offered 5 4 3 2 1 Convenience of program location 5 4 3 2 1 Waiting: Sessions were started on time 5 4 3 2 1 Sessions ended on time 5 4 3 2 1 Staff: Program leader Prepared and organized 5 4 3 2 1 Knowledgeable about subject matter 5 4 3 2 1 Ability to explain material 5 4 3 2 1 Gives good advice and treatment 5 4 3 2 1 Interest and enthusiasm 5 4 3 2 1 Listens to you 5 4 3 2 1 Takes enough time with you 5 4 3 2 1 Encouraged discussion 5 4 3 2 1 Answered questions 5 4 3 2 1 Friendly 5 4 3 2 1 Other staff: Friendly 5 4 3 2 1 Answered questions 5 4 3 2 1
Please circle how well you think we are doing in the following areas: Program: GREAT GOOD I liked having the program in a group format 5 4 3 2 1 It was helpful to hear about others experiences 5 4 3 2 1 Talking about my experiences to others was helpful 5 4 3 2 1 I got enough attention from the leader 5 4 3 2 1 The number of sessions was good 5 4 3 2 1 The amount of time for each session was good 5 4 3 2 1 The amount of time between sessions was good 5 4 3 2 1 Keeping a sleep diary was helpful for me 5 4 3 2 1 Facility: Neat and clean building 5 4 3 2 1 Comfort and safety while waiting 5 4 3 2 1 Privacy 5 4 3 2 1 Good learning environment 5 4 3 2 1 Room was comfortable 5 4 3 2 1 Confidentiality: Keeping my personal information private 5 4 3 2 1 The likelihood of referring others to the CBT-I program: 5 4 3 2 1 5 4 OK 3 FAIR 2 POOR 1 What do you like best about our program? What do you like least about our program? Suggestions for improvement? Thank you for completing our Survey! Adapted from Health Resources and Services Administration. Health Center Program: The Health Center Patient Satisfaction Survey.
CBT-I Resources Carstens, J. (2009). Evidence summary: Insomnia management. JBI Library of Systematic Review. Retrieved from: http://connect.jbiconnectplus.org.ezproxy.valpo.edu/viewpdf.aspx?0=991&1=1 Cbtforinsomnia.com Edinger, J. D. & Carney, C. E. (2008). Overcoming insomnia: A cognitive-behavioral approach: Therapist guide. New York: Oxford University Press, Inc. Edinger, J. D. & Carney, C. E. (2008). Overcoming insomnia: A cognitive-behavioral approach: Workbook. New York: Oxford University Press, Inc. Espie, C. A. (2009). Stepped care : A health technology solution for delivering cognitive behavioral therapy as a first line insomnia treatment. Sleep, 32, 1549-1558. Jacobs, G. (2010). Clinical training manual for a CBT insomnia program. Worcester: University of Massachusetts Medical Center. Jacobs, G. (1998). Say good night to insomnia. New York: Henry Holt and Company, LLC. National Guideline Clearinghouse. (2008). Clinical guideline for the evaluation and management of chronic insomnia in adults. Retrieved from: http://www.guideline.gov Perlis, M. L., Jungquist, C., Smith, M. T., & Posner, D. (2005). Cognitive behavioral treatment of insomnia: A session by session guide. New York: Springer Science+Business Media, LLC. Perlis, M. L., & Smith, M. T. (2008). How can we make CBT-I and other BSM services more widely available? Journal of Clinical Sleep Medicine, 4(1), 11-13. Schutte-Rodin, S., Broch, L., Buysse, D., Dorsey, C., & Sateia, M. (2008). Clinical guideline for the evaluation and management of chronic insomnia in adults. Journal of Clinical Sleep Medicine, 4, 487-504. Smith, M. T., & Perlis, M. L. (2006). Who is a good candidate for cognitive-behavioral therapy for insomnia? Health Psychology, 25(1), 15-19. doi:10.1037/0278-6133.25.1.15 Taylor, D. J., Schmidt-Nowara, W., Jessop, C. A., & Ahearn, J. (2010). Sleep restriction therapy and hypnotic withdrawal versus sleep hygiene education in hypnotic using patients with insomnia. Journal of Clinical Sleep Medicine, 6(2), 169-175.