Insomnia Follow Up Form | Sleep Study

Full Name*

Full Name

Date of Birth*

Date of Birth

ISI

The Insomnia Severity Index has seven questions. For each question, please SELECT the number that best describes your answer. Please rate the CURRENT (i.e. LAST 2 WEEKS) SEVERITY of your insomnia problem(s).

Difficulty falling asleep*

Difficulty falling asleep

Difficulty staying asleep*

Difficulty staying asleep

Problems waking up too early*

Problems waking up too early

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

How SATISFIED/DISSATISFIED are you with your CURRENT sleep pattern?

How NOTICEABLE to others do you think your sleep problem is in terms of impairing the quality of your life?*

How NOTICEABLE to others do you think your sleep problem is in terms of impairing the quality of your life?

How WORRIED/DISTRESSED are you about your current sleep problem?*

How WORRIED/DISTRESSED are you about your current sleep problem?

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, etc.) CURRENTLY?*

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, etc.) CURRENTLY?

SNQ

Based on the previous week:

Did you feel tired or fatigued during the day or evening?*

Did you feel tired or fatigued during the day or evening?

Were you sleepy or drowsy during the day or evening?*

Were you sleepy or drowsy during the day or evening?

Did you take any naps or fall asleep briefly during the day or evening?*

Did you take any naps or fall asleep briefly during the day or evening?

Did you feel you had been getting an adequate amount of sleep?*

Did you feel you had been getting an adequate amount of sleep?

Functional Outcomes of Sleep Questionnaire (FOSQ)

Some people have difficulty performing everyday activities when they feel tired or sleepy. The purpose of this questionnaire is to find out if you generally have difficulty carrying out certain activates because you are too sleep oy tired. In this questionnaire, when the words “sleepy” or “tired” are used, it means the feeling that you can’t keep your eyes open, your head is droopy, that you want to “nod off”, or that you feel the urge to take a nap. These words do not refer to the tired or fatigued feeling you may have after you have exercised. Directions: Please put a mark in the box for your answer to each question. Select only ONE answer for each question. Please try to be as accurate as possible. All information will be kept confidential.

1. Do you have difficulty concentrating on the things you do because you are sleepy or tired?*

1. Do you have difficulty concentrating on the things you do because you are sleepy or tired?

2. Do you generally have difficulty remembering things because you are sleepy or tired?*

2. Do you generally have difficulty remembering things because you are sleepy or tired?

3. Do you have difficulty operating a motor vehicle for short distances (less than 100 miles) because you become sleepy or tired?*

3. Do you have difficulty operating a motor vehicle for short distances (less than 100 miles) because you become sleepy or tired?

4. Do you have difficulty operating a motor vehicle for long distances (greater than 100 miles) because you become sleepy or tired?*

4. Do you have difficulty operating a motor vehicle for long distances (greater than 100 miles) because you become sleepy or tired?

5. Do you have difficulty visiting with your family or friend in their home because you become sleep or tired?*

5. Do you have difficulty visiting with your family or friend in their home because you become sleep or tired?

6. Has your relationship with family, friends, or work with family, friends, or work colleagues been affected because you are sleepy or tired?*

6. Has your relationship with family, friends, or work with family, friends, or work colleagues been affected because you are sleepy or tired?

7. Do you have difficulty watching a movie or videotape/disc because you become sleepy or tired?*

7. Do you have difficulty watching a movie or videotape/disc because you become sleepy or tired?

8. Do you have difficulty being as active as you want to be in the evening because you are sleepy or tired?*

8. Do you have difficulty being as active as you want to be in the evening because you are sleepy or tired?

9. Do you have difficulty being as active as you want to be in the morning because you are sleepy or tired?*

9. Do you have difficulty being as active as you want to be in the morning because you are sleepy or tired?

10. Has your desire or intimacy for sex been affected because you are sleepy or tired?*

10. Has your desire or intimacy for sex been affected because you are sleepy or tired?

How Did You Hear About Us?*

If Other Please Specify?

Please confirm.