RESTORE Pre-Screening Survey

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Are you aged 18-75?* This field is required.
YESNO
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Do you suffer from ongoing insomnia? * This field is required.
YESNO
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Have you previously received treatment for severe insomnia?* This field is required.This includes both drug treatments and behavioural therapies, such as Cognitive Behavioural Therapy
YESNO
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What gender are you?* This field is required.
Male
Female
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Are you pregnant or do you plan to become pregnant in the next 12 months?* This field is required.
YESNO
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Please now complete the ‘Insomnia Severity Index’ questionnaire, which will assess your insomnia

Insomnia Severity Index

The Insomnia Severity Index has seven questions. The seven answers are added up to get a total score. When you have
your total score, look at the 'Guidelines for Scoring/Interpretation' below to see where your sleep difficulty fits.

For each question, please SELECT the number that best describes your answer.

Please rate the CURRENT (i.e. LAST 2 WEEKS) SEVERITY of your insomnia problem(s).

Click "Next" to continue.
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1. Insomnia Problem - Difficulty falling asleep* This field is required.
None
Mild
Moderate
Severe
Very Severe
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2. Insomnia Problem - Difficulty staying asleep * This field is required.
None
Mild
Moderate
Severe
Very Severe
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3. Insomnia Problem - Problems waking up too early* This field is required.
None
Mild
Moderate
Severe
Very Severe
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4. How SATISFIED/DISSATISFIED are you with your CURRENT sleep pattern? * This field is required.
Very Satisfied
Satisfied
Moderately Satisfied
Dissatisfied
Very Dissatisfied
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5. 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
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6. 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
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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?* This field is required.
Not at all Interfering
A Little
Somewhat
Much
Very Much Interfering
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ISI Score
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Are you currently taking any antidepressants, antipsychotics, or anticoagulants?
YES
NO
UNSURE
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Great, you're likely to be eligible for this study! Do you consent to the information entered here being stored by Lindus Health, subject to the terms of our privacy policy, and being shared with the research team?* This field is required.This is required so that the study can contact you with further details about participation. We will never share your data without your explicit consent. We may contact you about relevant future research opportunities, and you can opt out of this at any time.
YESNO
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What is your name?* This field is required.In the following questions, we will just ask for your name, email, and phone number so that the research team can contact you.
First Name
Last Name
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What is your preferred name?* This field is required.
Preferred Name
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And what’s your email address?* This field is required.
example@example.com
example@example.com
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And finally, your phone number?* This field is required.Your mobile number will only be shared with the research team to contact you about this study.
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How did you hear about the study?* This field is required.E.g. Received a text through GP practice, Social Media, Sleep Clinic
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Thank you for completing this survey! You're now ready to for the next step which is a call with the study nurse.

Please click "SUBMIT" and you will be redirected to Calendly to book a screening call with the study nurse.

If you have any questions, please email restore@lindushealth.com
or call us on 0800 058 4113
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