Insomnia Scale

Insomnia Severity Index

Please answer as honestly as you can.
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Patient Name:*

First NameLast Name
Date Of Birth:*

MonthDayYear
Date
Email*
example@example.com

Over the last two weeks, how often have you been bothered by the following problems?*

4.) How SATISFIED/DISSATISFIED are you with your CURRENT sleep pattern?*

Very Satisfied (0)Satisfied (1)Moderately Satisfied (2)Dissatisfied (3)Very Dissatisfied (4)
5.) How NOTICEABLE to others do you think your sleep problem is in terms of impairing the quality of your life?*

Not At All Noticeable (0)A Little (1)Somewhat (2)Much (3)Very Much Noticeable (4)
6.) How WORRIED/DISTRESSED are you about your current sleep problem?*

Not At All Worried 0)A Little (1)Somewhat (2)Much (3)Very Much Worried (4)
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?*

Not At All Interfering 0)A Little (1)Somewhat (2)Much (3)Very Much Interfering (4)
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)

Reference: Used via courtesy of www.myhealth.va.gov with permission from Charles M. Morin, Ph.D., Université Laval
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Insomnia Severity Index