ISI ESS Review Questionnaire

ISI ESS Review Questionnaire
Submission Date

DayMonthYear
ISI Score
ESS Score
First Name*
Middle Name
Last Name*
Epworth Sleepiness Scale (ESS)

In the following situations, please rate how likely you are to fall asleep
Sitting and reading*
Watching TV*
Sitting quietly after lunch without alcohol*
Sitting and talking to someone*
Sitting quietly in a public place*
Lying down to rest in the afternoon*
As a passenger in a car for an hour without a break*
In a car stopped in traffic*
Insomnia Severity Index

Please answer the following questions based on your current sleep perceptions (approximately the last two weeks).
Please rate how SEVERE your difficulty in falling asleep is:*
Please rate how SEVERE your difficulty staying asleep is:*
Please rate how SEVERE your problem waking too early in the morning is:*
How SATISFIED are you with your current sleep pattern?*
How NOTICEABLE to others do you think your sleep problem is in terms of impairing your quality of life*
How WORRIED/DISTRESSED are you about your current sleeping problem*
To what extent do you consider your current sleep problem to INTEREFERE with your daily functioning (e.g. daytime fatigue/mood/ability to work/concentration/memory etc.*
Should be Empty:

Epworth Sleepiness Scale (ESS)