Sleep Questionnaire
Pittsburgh Sleep Quality Index (PSQI)
Name
First Name
Last Name
Email
example@example.com
Mobile
Please enter a valid phone number.
Format: +00 (000) 000-0000.
During the past month, when have you usually gone to bed at night? (Bedtime)
During the past month, how long (in minutes) has it usually taken you to fall asleep each night?
During the past month, when have you usually gotten up in the morning? (Wake time)
During the past month, how many hours of actual sleep did you get at night?
During the past month, how often have you had trouble sleeping because you...
Rows
1 - 3 times
4 - 6 times
more than 6 times
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 bad dreams
Have pain
During the past month, how often have you had trouble sleeping because you cannot get to sleep within 30 minutes
1
2
3
4
5
1 is , 5 is
During the past month, how often have you had trouble sleeping because you wake up in the middle of the night or early morning
1
2
3
4
5
1 is , 5 is
During the past month, how would you rate your sleep quality overall?
During the past month, how often have you taken medicine (prescribed or “over the counter”) to help you sleep?
During the past month, how often have you had trouble staying awake while driving, eating meals, or engaging in social activity?
During the past month, how much of a problem has it been for you to keep up enthusiasm to get things done?
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Epworth Sleepiness Scale (ESS)
How likely are you to doze off or fall asleep in the following situations, in contrast to just feeling tired? This refers to your usual way of life in recent times. Even if you haven't done some of these things recently, try to work out how they would have affected you. Use the following scale to choose the most appropriate number for each situation: 0 = would never doze 1 = slight chance of dozing 2 = moderate chance of dozing 3 = high chance of dozing
Rows
0
1
2
3
1. Sitting and reading
2. Watching TV
3. Sitting, inactive in a public place (e.g., a theatre or a meeting)
4. As a passenger in a car for an hour without a break
5. Lying down to rest in the afternoon when circumstances permit
6. Sitting and talking to someone
7. Sitting quietly after a lunch without alcohol
8. In a car, while stopped for a few minutes in traffic
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Insomnia Severity Index (ISI)
For the following questions, please consider the last 2 weeks
None (0), Mild (1), Moderate (2), Severe (3), Very Severe (4).
Rows
0
1
2
3
4
1. Difficulty falling asleep
2. Difficulty staying asleep
3. Problems waking up too early
Very Satisfied (0), Satisfied (1), Neutral (2), Dissatisfied (3), Very Dissatisfied (4).
Rows
0
1
2
3
4
4. Satisfaction with your current sleep pattern
5. How noticeable to others do you think your sleep problem is, in terms of impairing the quality of your life?
6. How worried/distressed are you about your current sleep problem?
7. To what extent do you consider your sleep problem to interfere with your daily functioning?
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STOP-BANG Questionnaire
Category 1: Risk Factors for Sleep Apnoea
1. Snoring: Do you snore loudly (louder than talking or loud enough to be heard through closed doors)?
Yes
No
2. Tiredness: Do you often feel tired, fatigued, or sleepy during the daytime?
Yes
No
3. Observed Apnoea: Has anyone observed you stop breathing during your sleep?
Yes
No
4. Blood Pressure: Do you have or are you being treated for high blood pressure?
Yes
No
5. BMI: Is your BMI more than 35 kg/m2?
Yes
No
6. Age: Are you over 50 years old?
Yes
No
7. Neck Circumference: Is your neck circumference greater than 40 cm?
Yes
No
8. Gender:
Male
Female
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Sleep Hygiene Index (SHI)
Answer with Never (0), Rarely (1), Sometimes (2), Frequently (3), Always (4)
Rows
0
1
2
3
4
1. I take daytime naps lasting two or more hours.
2. I go to bed at different times from day to day.
3. I get out of bed at different times from day to day.
4. I exercise to the point of sweating within 1 hour of going to bed.
5. I stay in bed longer than I should two or three times a week.
6. I use alcohol, tobacco, or caffeine within 4 hours of going to bed or after going to bed.
7. I do something that may wake me up before bedtime (watch TV, use a phone, play video games).
8. I go to bed feeling stressed, angry, upset, or nervous.
9. I use my bed for things other than sleeping or sex (watch TV, read, eat, or study).
10. I sleep on an uncomfortable bed (e.g., poor mattress or pillow, too much or not enough bedding).
11. I sleep in an uncomfortable bedroom (e.g., too bright, too stuffy, too hot, too cold, or too noisy).
12. I do important work before bed (e.g., pay bills, schedule commitments, or study).
13. I think, plan, or worry when I am in bed.
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Morningness-Eveningness Questionnaire (MEQ)
1. If it were entirely up to you, at what time would you get up?
2. If it were entirely up to you, at what time would you go to bed?
3. Do you find it easy to get up in the morning?
4. Do you feel alert during the first half hour after waking in the morning?
5. How is your appetite during the first half hour after waking in the morning?
6. How alert do you feel in the evening?
7. How is your energy level in the evening?
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