PSQI

Instructions: The following questions relate to your usual sleep habits during the past month only. Your answers should indicate the most accurate reply for the majority of days and nights in the past month. Please answer all questions.

Name

First NameLast Name

Date of Birth

Date

Last 4 digits of Social Security Number

PSQI SCORE

Component 1: Sleep Quality

Component 2: Sleep Latency

Component 3: Sleep Duration

Component 4: Sleep Efficiency

Component 5: Sleep Disturbance Domain Score

Component 6: Sleep Medication

Component 7: Daytime Dysfunction

Over the past month, what time did you usually try to go to bed?

Hour Minutes

AM/PM Option

Over the past month, what time have you usually woken up?

Hour Minutes

AM/PM Option

How many hours in bed is that?*

Enter a single number, not a range (i.e: 7-8)

Approximately how many minutes does it take you to fall asleep?*

Do not enter a range (i.e: 15-20)

Sleep Latency Score

Component 2 Subtotal

During the past month, approximately how many hours of actual sleep did you get each night (this may be different than the number of hours you spent in bed)?*

Do not enter a range (i.e: 7-8)

Component 4: Sleep Efficiency Subtotal

During the past month, how often have you had trouble sleeping because you...

Rows	Not During the Past Month	Less than Once a Week	Once or Twice a Week	Three or More Times a Week
Cannot get to sleep within 30 minutes
Wake up in the middle of the night or early morning
Have to get up to use the bathroom
Cannot breathe comfortably
Cough or snore loudly
Feel too cold
Feel too hot
Have pain
Other reason(s)

Sleep Disturbance Subtotal Score

During the past month, how often have you taken medicine to help you sleep (prescribed or “over the counter”)? (eg: Ambien, Melatonin, NyQuil)

Not during the past monthLess than once per weekOnce or twice per weekThree or more times per week

During the past month, how often have you had trouble staying awake while driving, eating meals, or engaging in social activity?

Not during the past monthLess than once per weekOnce or twice per weekThree or more times per week

During the past month, how much of a problem has it been for you to keep up enough enthusiasm to get things done?

No problem at allOnly a slight problemSomewhat of a problemA very big problem

Component 7: Daytime Dysfunction Subtotal

During the past month, how would you rate your sleep quality overall?

Very goodFairly goodFairly badVery bad

Do you have a bed partner or roommate?

No bed partner or room matePartner/room mate in other roomPartner in same room but not same bedPartner in same bed

If you have a roommate or bed partner, ask him/her how often in the past month you have had:

Rows	Not During the Past Month	Less than Once a Week	Once or Twice a Week	Three or More Times a Week
Loud snoring
Long pauses between breaths while asleep
Legs twitching or jerking while asleep
Episodes of disorientation or confusion durning sleep
Other restlessness while you sleep

NSA: PSQI