Assess Your Insomnia With Our Online Questionnaire!

1

Email* This field is required.Please enter your email to begin completing the questionnaire.

2

Please rate the CURRENT (i.e. LAST 2 WEEKS) SEVERITY of your difficulty falling asleep* This field is required.

None

Mild

Moderate

Severe

Very Severe

3

Please rate the CURRENT (i.e. LAST 2 WEEKS) SEVERITY of your difficulty staying asleep* This field is required.

None

Mild

Moderate

Severe

Very Severe

4

Please rate the CURRENT (i.e. LAST 2 WEEKS) SEVERITY of your problem waking too early* This field is required.

None

Mild

Moderate

Severe

Very Severe

5

How SATISFIED/DISSATISFIED are you with your CURRENT sleep pattern?* This field is required.

Very Satisfied

Satisfied

Moderately Satisfied

Dissatisfied

Very Dissatisfied

6

How NOTICEABLE to others do you think your sleep problem is in terms of impairing the quality of your life?* This field is required.

Not At All Noticeable

A Little

Somewhat

Much

Very Much Noticeable

7

How WORRIED/DISTRESSED are you about your current sleep problem?* This field is required.

Not At All Worried

A Little

Somewhat

Much

Very Much Worried

8

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?* This field is required.

Not At All Interfering

A Little

Somewhat

Much

Very Much Interfering

9

Calculation