Unique Patient ID
These questions are based on the Insomnia Severity Index that attempts to define the severity of both the nighttime and daytime impacts of insomnia over the past month.
Difficulty falling asleep*

1

2

3

4

5

1 is Not Difficult, 5 is Very Difficult
Difficulty staying asleep*

1

2

3

4

5

1 is Not Difficult, 5 is Very Difficult
Do you have problems waking up too early?*

1

2

3

4

5

1 is Never, 5 is Always
How satisfied are you with your current sleep pattern?*

1

2

3

4

5

1 is Very Satisfied, 5 is Very Unsatisfied
How noticeable to others do you think your sleep problem is in terms of impairing the quality of your life*

1

2

3

4

5

1 is Not noticeable, 5 is Very noticeable
How worried are you about your current sleep problem?*

1

2

3

4

5

1 is Not worried, 5 is Very worried
How disruptive to your daily life do you think your sleep problem is?*

1

2

3

4

5

1 is Not disruptive, 5 is Very disruptive
ISI SCORE
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