Save as Text. Complete the questionnaire by putting your answers on the line following the question. You can enter as many lines as you want. Print it out and give it to your health care provider.
SLEEP QUESTIONNAIRE
This questionnaire has been developed through study of sleep research and publications, sleep medicine resources, clinical work in counseling, and study and practice of dreams and the psyche.
BASIC INSTRUCTIONS:
The questionnaire has lots of questions. Some may seem repetitive, but to fully identify the sleep problem there are slightly different aspects of an issue that must be explored.
There are many factors to consider when looking into a sleep problem. Each of the questions is designed to address one or more sleep factor. We are trying to balance out the need for complete information with the concern of too much question-answering work on your part. However, it may be that the questions will spark some new thoughts or questions of your own. If that happens please write your thoughts and/or questions down anywhere on the questionnaire or on the back.
To give yourself an opportunity for meaningful answers, allow yourself some time (and space) to respond to the items on the sleep questionnaire thoughtfully. Your bed-partner will need to review and comment on your answers. Sometimes bed-partners give pieces of information that are crucial to the accurate determination of the problem.
If you don't want to answer any particular question you don't have to. Simply mark that question either "DWA" or "Don't want to answer". You may be asked about any DWA's and you can discuss privately the issues involved. You shouldn't be forced to answer any question, and there may be another way to find the information about your sleep problem.
This questionnaire is copyrighted 1996-98 by Sarah Richards
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Your Name:
Address:
City, State & Zip/Postal code:
Country:
Phone:
email address:
Your height:
Your weight:
Your Date of Birth:
Type of Work You Do:
1) How long have you been suffering from insomnia?
2) Do you have a problem getting to sleep?
3) Do you wake up too early in the morning?
4) Can you predict whether you’ll have a good or poor night’s sleep?
5) Do you have a problem staying awake during the day?
6) How often during the week do you have a problem with falling sleep or staying asleep?
7) On a typical night how many times do you wake up in the night?
8) What wakes you up at night? For instance it may be noises, needing to go to the bathroom, pain, a child...
9) When you do wake up in the night, how long do you usually stay awake?
10) How many hours of sleep do you typically get per night?
11) When you spend more time in bed do you get more sleep and feel better the next day?
12) Were there any stressful life events related to the start of your sleep difficulty? For instance, a death of someone you loved, divorce, retirement, medical or emotional problems, a move, travel...
13) Has the sleep difficulty been gradually increasing or was it sudden?
14) Has your insomnia been persistent, seasonal, only occurring at certain times, or have you noticed other patterns?
15) What types of things make your sleep worse?
16) What impact does insomnia have on your life? For instance does your mood change, do you have trouble staying awake during the day? is your performance impaired?
17) How do you cope with daytime effects of insomnia?
18) How much do you think your sleep problem interferes with your daily functioning? For instance with your mood, memory, concentration, ability to function at work or with daily chores, or with daytime fatigue.
19) How is your memory, both long and short-term? Are you having difficulty with forgetfulness?
20) Are you noticing changes in your mood or behaviors?
21) How noticeable to others do you think your sleeping problem is and what do you think they notice?
22) Do you feel tired, exhausted, washed out, or sleepy during the day?
23) Does it show in your physical appearance when you don’t sleep well?
24) What do you think is influencing your sleep problem?
25) How old are you?
26) How much liquid do you drink in the evening?
27) Do you have asthma?
28) Do you have an allergy, congested nose, or coughing that bothers you at night?
29) Do you have medical problems that keep you awake at night?
30) When do you eat your largest meal? Do you eat before going to bed? If so, what? Do you eat in bed?
31) Do you fee like eating?
32) How much sugar do you eat or drink? (Include desserts, pop, treats, snacks...) When do you typically consume it?
33) Do you or have you used alcohol to help you sleep? If so, how much and how many nights per week?
34) How much alcohol do you drink?
35) Have you ever been treated for substance abuse problems?
36) Have you ever awakened in the morning after some drinking the night before and found you could not remember a part of the evening before?
37) Have you ever had trouble with alcohol or drugs?
38) Do you take medications that contain: caffeine, ephedrine, or amphetamine?
39) Are you taking weight-loss products or stimulants? If so, which ones and when do you take them?
40) What prescription drugs, dietary supplements including vitamins, and over-the-counter drugs are you taking? When do you take them?
41) Do you use sleeping pills? Have you used them within the last month? What kind and how much do you use?
42) When, or under what conditions, do you sleep the best?
43) Do you have children under 5? If so, what are their ages?
44) Do you have arthritis, back pain, or other pain that keeps you awake?
45) Have you ever been admitted to a hospital for a psychiatric condition?
46) Are you concerned or irritated by your sex life?
47) Please describe any changes in your sex drive since you’ve had troubles with sleep.
48) What do you tell yourself about your sleep?
49) What is your usual bedtime on weekdays?
50) At what time do you usually wake up in the morning (or afternoon/evening) for the last time?
51) What time do you usually get out of bed in the morning (or afternoon/evening)?
52) What is your usual bedtime on weekends?
53) How is your waking and getting up different on weekends than during the week?
54) Do you read in bed?
55) How many times per week do you exercise?
56) What kind of exercise to you get?
57) Do you sometimes exercise prior to going to bed?
58) How much caffeine do you drink (coffee, tea, soda)? How much after dinner?
59) How many cigarettes per day do you smoke?
60) Describe your bedtime routine.
61) What do you do when you can’t fall asleep or stay asleep?
62) Is your sleep better or worse on the weekends?
63) Do you have time to unwind before bed?
64) Do you go to bed when you are drowsy?
65) Do you take a hot shower or bath before bed?
66) Do you sleep with a bed partner?
67) Do you have a problem staying asleep?
68) How long does it take you to get to sleep after you’ve gone to bed?
69) Do you have difficulty thinking of words (but for the most part can communicate normally) or feel like your mental process has slowed?
70) Do you make occasional mistakes or have failures in thinking and speech which can be corrected easily?
71) a) Do you lose your train of thought, forget what you are thinking or talking about, leave statements incomplete, etc. (b) Do you have sudden unexplained shifts in your trend of thought or speech that you can correct with effort if asked?
72) a) Do some of your thoughts or statements become completely incoherent and you find that you can’t clarify them? b) Do you confuse fantasies, dreams, or intrusive thoughts with reality?
73) Do you find yourself rambling, having incoherent speech for brief periods with a failure to recognize errors? Have you been unable to straighten out the jumble of incoherent thoughts when asked?
74) Does time seem to pass slowly, or to be “different” in duration?
75) Do you have occasional mistakes in thinking about time but find yourself correcting that spontaneously?
76) Do you have occasional mistakes in thinking about time and not recognizing the error until someone questions you?
77) Do you make frequent mistakes about time which you believe to be correct and are uncertain when someone confronts you?
78) Do you or have you been very disoriented in time or had an unshakable belief in your concept of time that was seen as mistaken by others?
79) Do you experience eye itching, burning or tired eyes, difficulty seeing, blurred vision, or diplopia?
80) Do you find yourself recognizing illusions but have no doubts about their being illusions (e.g. Looks like fog around the light)?
81) Do you find yourself recognizing illusions but having some doubts about their reality?
82) Do you recognize illusions but, for a time at least, believe they are real?
83) Do you feel irritable, tense, nervous, groggy, depressed, anxious, grouchy, hostile, angry, or confused?
84) How many of the following do you think contribute to your sleep problem? Racing thoughts at night Muscular tension or pain Bad sleeping habits Natural aging process
85) Have you ever been afraid of going out of the house alone, being in crowds, standing in a line, or traveling on buses, planes or trains?
86) In the last 6 months have you been particularly nervous, restless, or anxious?
87) Do you worry a lot?
88) Do you experience any of the following? Rapid or irregular heart beat Frequent urination and/ or Diarrhea Dry mouth Sweating Flushing and pallor Cold hands
89) Do you have difficulties slowing down or relaxing?
90) Are your hands often sweaty, clammy, or extremely cold?
91) Do you have a ringing in your ears or tinnitus?
92) Is your bedroom secure?
93) Do you often have feelings of apprehension, anxiety, or dread when you’re getting ready for bed?
94) Do you often worry about things you’ve said that might have hurt somebody’s feelings?
95) Has anything happened lately that has been especially hard for you? For instance trouble at work, at home, with friends or family members, with your health?
96) Do you see changes in or loss of shape, size, movement, color or texture consistancies? Do you have disturbed depth perception?
97) Is your bed comfortable?
98) Is your bedroom quiet?
99) Do you have a TV or electronic devices in your bedroom, or other things that may ordinarily be found elsewhere in the house?
100) What is the temperature of your bedroom at night?
101) How much light is present in your bedroom when you sleep?
102) Is your sleep better or worse when you are away from home?
103) Do you tend to fall asleep or get drowsy when you are driving? Have you ever gotten into an accident after falling asleep at the wheel?
104) On a typical night how long do you think it takes you to fall asleep?
105) Do you wet your bed?
106) Have you ever taken any anti-depressant or anti-anxiety medication?
107) Have you been less interested in things you used to enjoy? If yes, does that happen nearly every day?
108) For the last couple of years or more have you been feeling down more often than not?
109) Are you bothered by things now that usually don’t bother you?
110) Do you feel you are as good as other people?
111) Do you have trouble keeping your mind on what you are doing?
112) Do you feel depressed? If you’ve been feeling depressed, how long has it been?
113) Do you feel everything you do is an effort?
114) Are you having crying spells or do you feel sad?
115) Are you pessimistic or discouraged about the future, feeling - maybe realistically - that the future is hopeless and that things will not improve?
116) Do you feel you are mostly a disappointment as a person (parent, husband, wife, child)? Are you disappointed in yourself?
117) Do you have thoughts of harming or killing yourself, or do you think it would be better if you were dead?
118) Are you being touched (physically) at this time in your life to your satisfaction? Please comment.
119) Are you using more alcohol or getting angrier or more irritable than usual?
120) Do you have a sour taste in your mouth, heartburn, or reflux?
121) Do you wake and find that you can’t move at first?
122) Do you ever become weak in the knees or even collapse completely, especially when you are excited?
123) Do you ever have dream-like experiences as you are falling asleep that you believe are real?
124) Do you suddenly feel you can’t move when you are falling asleep?
125) Have you fallen asleep while doing routine tasks and when waking found that you hadn’t stopped doing that task while asleep?
126) When you remember your dreams are they vivid and very clear or are they hazy and difficult to remember.
127) Are you waking from dreaming feeling disturbed, frightened or disoriented?
128) Do you wake often due to dreams (good or bad dreams)?
129) Do you have frequent nightmares? If so, how often do you have them?
130) Do you experience flashbacks?
131) For women: Have you started or passed menopause?
132) If you are a woman, does your menstrual cycle affect your sleep? If so, how?
133) Are you on hormone replacement therapy such as thyroid or estrogen? If so, when do you take it?
134) Do you grind your teeth at night?
135) Do you work a rotating shift at work?
136) Do you work a night shift?
137) Have you noticed crawling or aching feelings in the legs (calves) and an inability to keep your legs still?
138) Have you (or your partner) noticed leg twitches or jerks during the night and/or waking up with cramps in your legs?
139) Have you ever had a panic attack when you felt suddenly scared, anxious, or very uncomfortable? How often?
140) If you wake in the night, what time do you usually wake?
141) Have you ever gotten counseling or psychotherapy? If so, for what?
142) Have you ever been bothered by thoughts that didn’t make sense and kept coming back to you even when you tried to stop them?
143) Do you ever fall asleep at inappropriate times or places?
144) Has your sleeping partner complained about your snoring and says it sounds like you stop breathing and then start snoring with an almost choking sound?
145) Do you have shortness of breath, morning headaches, chest pain, or dry mouth?
146) Do you have sleep attacks in which you fall asleep uncontrollably?
147) Do you wake feeling unrefreshed after a normal amount of sleep?
148) How often do you take naps?
149) Do you experience muscle aches and pain, lightheadedness, nausea, heartburn, muscle tension?
150) Do you have trouble with dizziness or poor night vision?
151) Does your family or house mates report that you scream at night but they can’t seem to wake you? Did you do that as a child?
152) Do you walk in your sleep or does your partner say you talk in your sleep?
153) In the last month, have you felt nervous and “stressed”?
154) Do you feel you are effectively coping with important changes that are occurring in your life?
155) Do you find that you can cope with all the things you have to do?
156) Are you able to control your response to the irritations in your life?
157) Do you feel like you’re on top of things?
158) Do you get angry because of things outside your control?
159) Can you control the way you spend your time?
160) Do you feel difficulties are piling up so high that you can’t overcome them?
161) Do you feel that you are able to control the important things in your life?
162) Has your sleep problem come around the same time as any loss such as death, divorce, moving, job change, child growing/leaving...?
163) Do you set time aside to deal with stress, e.g. list next day’s tasks?
164) Do you engage in stimulating activity before sleep, e.g. watching tv, sexual intercourse (for some), arguments?
165) Do you often work in the evening right up to the time you go to bed?
166) Are you under a great deal of stress at home or at work?
167) Do you travel? How much? How do you manage difficulties with crossing time-zones?
168) How many hours of sleep per night do you believe you need?
169) If you don’t get a proper amount of sleep on a given night do you try to make it up by napping or sleeping longer the next night?
170) Do you think you need more or less sleep as you get older?
171) Do you think you’ll have to pay for it the next night if you get a good night’s sleep?
172) Do you feel it is difficult to lead a satisfactory life despite sleep difficulties?
173) Is your sleep getting worse all the time and you wonder if help is impossible?
174) Does a poor night’s sleep interfere with your activities or your moods the next day?
175) Is insomnia ruining your ability to enjoy life and do what you want?
176) Do you avoid or cancel obligations (social, family, occupational) after a poor night’s sleep?
177) Have you received treatment for insomnia in the past? If so, what kind?
178) Have you been taught and used relaxation techniques?
179) What have you already done on your own to try to solve your sleep problem?
180) How worried or concerned are you about your sleep?
181) What prompted you to seek help for insomnia now?
182) How effective do you think treatment will be for your insomnia?
183) What do you think will hamper the effectiveness of insomnia treatment?
184) What kinds of health care professionals do you use? For instance, doctors, emergency room only, nurse practitioners, counselors or psychologists, chiropractors, naturopaths, other alternative care.
185) Do you believe that taking a sleeping pill is better than having a poor night’s sleep so you can be alert and function well during the day?
186) Do you think insomnia is essentially the result of a chemical imbalance?
187) Have you ever used sleeping medications?
188) When did you first use sleeping medications?
189) When did you last use sleep medications?
190) Do you believe that because your bed partner can fall asleep right away you should, too?
191) Are you worried that chronic insomnia may affect your physical health?
192) Are you worried that you may lose control over your ability to sleep?
193) Are you concerned about having a nervous breakdown if you don’t get sleep for one or two nights?
194) Are you sometimes afraid of dying in your sleep?
195) Is your sleep schedule disturbed for the whole week if you have one bad night’s sleep?
196) Do you experience any of the following? Backache and/or headache Catchy breathing and/or hyperventilation Difficulty swallowing Edginess and/or being easy to startle Going numb Muscle tension
197) Do you experience any of the following? Anxious tension or angst Butterflies in your stomach Extreme worry or concentration difficulties Decreased sex drive Feelings of dread or hypervigilance A sensation of “going crazy”
198) When you have trouble getting to sleep do you stay in bed and try harder to sleep?
199) Do you often work more than ten hours a day or more than six days a week?
200) Do you take less than two weeks of vacation a year?
201) Are any relationships with your family, friends, or co-workers unsatisfactory, or is there much stress in some important relationship?
202) Has your appetite changed?