PSQI

2. During the past month, how long (in minutes) has it usually taken you to fall asleep each night?

3. During the past month, what time have you usually gotten up in the morning?

4. During the past month, how many hours of actual sleep did you get at night? (This may be different than the number of hours you spent in bed.)

 >7h
 6-7h
 5-6h
 <5h

a) ...cannot get to sleep within 30 minutes

 Not during the last month
 Less than once a week
 Once or twice a week
 Three o more times a week

b) ...wake up in the middle of the night or early morning

 Not during the last month
 Less than once a week
 Once or twice a week
 Three o more times a week

c) ...have to get up to use the bathroom

 Not during the last month
 Less than once a week
 Once or twice a week
 Three o more times a week

d) ...cannot breathe comfortably

 Not during the last month
 Less than once a week
 Once or twice a week
 Three o more times a week

e) ...cough or snore loudly

 Not during the last month
 Less than once a week
 Once or twice a week
 Three o more times a week

f) ...feel too cold

 Not during the last month
 Less than once a week
 Once or twice a week
 Three o more times a week

g) ...feel too hot

 Not during the last month
 Less than once a week
 Once or twice a week
 Three o more times a week

h) ...have bad dreams

 Not during the last month
 Less than once a week
 Once or twice a week
 Three o more times a week

i) ...have pain

 Not during the last month
 Less than once a week
 Once or twice a week
 Three o more times a week

j) ...other reason(s), please describe:

 Not during the last month
 Less than once a week
 Once or twice a week
 Three o more times a week

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

 Very good
 Fairly good
 Fairly bad
 Very bad

7. During the past month, how often have you taken medicine to help you sleep (prescribed or “over the counter”)?

 Not during the last month
 Less than once a week
 Once or twice a week
 Three o more times a week

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

 Not during the last month
 Less than once a week
 Once or twice a week
 Three o more times a week

9. 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 all
 Only a very slight problem
 Somewhat of a problem
 A very big problem

10. Do you have a bed partner or room mate?

 No bed partner or room mate
 Partner/room mate in other room
 Partner in same room but not same bed
 Partner in same bed

a) Loud snoring:

 Not during the past month
 Less than once a week
 Once or twice a week
 Three o more times a week

b) Long pauses between breaths while asleep:

 Not during the past month
 Less than once a week
 Once or twice a week
 Three o more times a week

c) Legs twitching or jerking while you sleep:

 Not during the past month
 Less than once a week
 Once or twice a week
 Three o more times a week

d) Episodes of disorientation or confusion during sleep:

 Not during the past month
 Less than once a week
 Once or twice a week
 Three o more times a week

e) Other restlessness while you sleep, please describe:

 Not during the past month
 Less than once a week
 Once or twice a week
 Three o more times a week