NeuroField’s Insomnia Qualifying Form
Please complete the form to verify your insomnia and proceed with your purchase.
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Instructions to Patient
This questionnaire is designed to measure the frequency, severity, chronicity, and emotional/cognitive burden of your sleep difficulties. Please respond based on your experience over the past 30 days. Mark one response per item. There are four sections (A–D). Your clinician will generate a weighted composite score and qualifying band from your answers.
Full Name
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First Name
Last Name
Email Address
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Date of Birth
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Month
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Day
Year
Date
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Section A — Nocturnal Sleep Disturbance
Section A — Nocturnal Sleep Disturbance
Over the past 30 days, how often has each of the following occurred? (Scale 0–4, Frequency-weighted)
1. I have trouble initiating sleep once I go to bed (takes more than 20 minutes to fall asleep).
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[0] Never (0 times per week)
[1] Seldom (less than 1 time per week)
[2] Occasional (1–2 times per week)
[3] Frequent (3–5 times per week)
[4] Nightly (6–7 times per week)
2. I wake during the night and struggle to return to sleep.
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[0] Never (0 times per week)
[1] Seldom (less than 1 time per week)
[2] Occasional (1–2 times per week)
[3] Frequent (3–5 times per week)
[4] Nightly (6–7 times per week)
3. I awaken earlier than intended and cannot resume sleep.
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[0] Never (0 times per week)
[1] Seldom (less than 1 time per week)
[2] Occasional (1–2 times per week)
[3] Frequent (3–5 times per week)
[4] Nightly (6–7 times per week)
4. My sleep feels light, fragmented, or non-restorative.
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[0] Never (0 times per week)
[1] Seldom (less than 1 time per week)
[2] Occasional (1–2 times per week)
[3] Frequent (3–5 times per week)
[4] Nightly (6–7 times per week)
5. I engage in clock-watching or become distressed about the time while trying to sleep.
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[0] Never (0 times per week)
[1] Seldom (less than 1 time per week)
[2] Occasional (1–2 times per week)
[3] Frequent (3–5 times per week)
[4] Nightly (6–7 times per week)
Section B — Daytime Functional & Emotional Impact
Section B — Daytime Functional & Emotional Impact
How much does your sleep quality affect each domain below? (Scale 1–5, Impact-weighted ×1.5)
6. Poor sleep impairs my focus, memory, or decision-making during the day.
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[1] Not at all (no problem)
[2] Slight (mild problem)
[3] Moderate (noticeable problem)
[4] Marked (significant problem)
[5] Extreme (severe problem)
7. Poor sleep affects my mood (irritability, sadness, anxiety, or emotional reactivity).
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[1] Not at all (no problem)
[2] Slight (mild problem)
[3] Moderate (noticeable problem)
[4] Marked (significant problem)
[5] Extreme (severe problem)
8. Poor sleep reduces my physical energy or causes daytime fatigue.
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[1] Not at all (no problem)
[2] Slight (mild problem)
[3] Moderate (noticeable problem)
[4] Marked (significant problem)
[5] Extreme (severe problem)
9. Poor sleep interferes with my work, school, household, or social responsibilities.
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[1] Not at all (no problem)
[2] Slight (mild problem)
[3] Moderate (noticeable problem)
[4] Marked (significant problem)
[5] Extreme (severe problem)
10. I feel distressed, worried, or hopeless about my sleep problems.
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[1] Not at all (no problem)
[2] Slight (mild problem)
[3] Moderate (noticeable problem)
[4] Marked (significant problem)
[5] Extreme (severe problem)
11. Others (family, coworkers) have noticed that my sleep problems affect my functioning.
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[1] Not at all (no problem)
[2] Slight (mild problem)
[3] Moderate (noticeable problem)
[4] Marked (significant problem)
[5] Extreme (severe problem)
Section C — Chronicity & Duration
Section C — Chronicity & Duration
Select the option that best describes the duration and pattern of your sleep problem. (Weighted ×1.25)
Duration of Insomnia
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Less than 2 weeks
2 weeks – 1 month
1 – 3 months
3 – 6 months
More than 6 months
13. On a typical week, how many nights are disrupted?
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0 – 1 nights
2 – 3 nights
4 – 5 nights
6 – 7 nights
14. How long has your overall life functioning been affected?
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Not affected
Recent (< 1 month)
1 – 3 months
3 – 12 months
Over 1 year
Section D — Pre-Sleep Cognitive & Somatic Arousal
Section D — Pre-Sleep Cognitive & Somatic Arousal
When attempting to sleep, how intense are the following experiences? (Scale 0–4, Weighted ×1.25)
15. Racing thoughts or mental replay when trying to sleep.
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[0] None (no symptoms)
[1] Mild (minor symptoms)
[2] Moderate (moderate symptoms)
[3] Strong (severe symptoms)
[4] Overwhelming (extreme symptoms)
16. Worry or anticipatory anxiety about not being able to sleep.
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[0] None (no symptoms)
[1] Mild (minor symptoms)
[2] Moderate (moderate symptoms)
[3] Strong (severe symptoms)
[4] Overwhelming (extreme symptoms)
17. Physical tension, restlessness, or elevated heart rate at bedtime.
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[0] None (no symptoms)
[1] Mild (minor symptoms)
[2] Moderate (moderate symptoms)
[3] Strong (severe symptoms)
[4] Overwhelming (extreme symptoms)
18. Sensitivity to environment (light, sound, temperature) that prevents sleep.
*
[0] None (no symptoms)
[1] Mild (minor symptoms)
[2] Moderate (moderate symptoms)
[3] Strong (severe symptoms)
[4] Overwhelming (extreme symptoms)
Supplementary Screen — Context & Contributing Factors
Supplementary Screen — Context & Contributing Factors
Current sleep medications or supplements (list):
Do you or have you ever suffered from one or more of the following:
Sleep Apnea
Depression
Reduced Sleep due to Medication
Caffeine / stimulant use after noon
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Yes
No
Sometimes
Alcohol or cannabis used to aid sleep
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Yes
No
Sometimes
Shift work, jet lag, or variable schedule
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Yes
No
Screen or device use within 30 min of bedtime
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Yes
No
Known medical / psychiatric condition impacting sleep?
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Signature
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Section A Sum Calculation
Section B Sum Calculation
Section C Sum Calculation
C12 Duration Score
Section D Sum Calculation
Composite Score Calculation
Approval Status
Approved
Not Approved
Submit for Physician Review
Should be Empty: