Survey Questionnaire

Insomnia Factors that Affect the Academic Performance, Mental Health and
Physical Health of Senior High School Students at ICCT Colleges Cainta
S. Y. 2022-2023

Thank you for participating in our research survey. Please answer the questions
honestly and to the best of your knowledge. Your responses will remain confidential and
will be used for research purposes only. Your input is valuable and will help us gain
insight into our study topic. Thank you for your time and cooperation.

The Researchers,
Dela Cruz, Maria Angeline
Escultura, Bon Angelo
Fernando, Fate
Floralde, Katrina Joy
Isaias, Myrrh Lynmuelh
Madriaga, Ivan Kyle
Part I. PROFILE OF THE STUDENTS
Name (Optional): Age: Gender: M F
General Average: 60-70: 70-80: 80-90: 90-100:

Part II. RESEARCH SURVEY QUESTIONS

Direction: Read each statement carefully. Put a check mark for a responses on each of
the following statement.
Scale Range Interpretation
5 4.01-5.00 Strongly Agree
4 3.01-4.00 Agree
3 2.01-3.00 Neutral
2 1.01-2.00 Disagree
1 0.01-1.00 Strongly Disagree
 Survey Questionnaire

Part III.
Direction: The following are the questions that show the insomnia factors that affect the
academic performance, mental health and physical health of SHS student at ICCT
Colleges Cainta. Put a check ( ) on the column the best fits to your answer.
The Effects of Insomnia Strongly Agree Neutral Disagree Strongly
on my Academic Agree Disagree
Performance
1. My academic
performance suffers
because of the sleep
disturbances caused by
insomnia.
2. I believe that improving
my sleep quality would
positively impact my
academic performance.
3. My insomnia
negatively affects my
ability to concentrate and
focus on my academic
work.
4. I have missed school
assignments or exams
because of insufficient
sleep caused by
insomnia.
5. Difficulty falling asleep
or staying asleep affects
my ability to concentrate
in school.
6. I find it challenging to
manage time effectively
for studying due to
insomnia.
7. I find it difficult to stay
awake and alert in class
due to insomnia.
8. Seeking support or
interventions to address
my insomnia would
positively impact my
academic performance.
 Survey Questionnaire

The Effects of Insomnia on Strongly Agree Neutral Disagree Strongly

my Physical Health Agree Disagree
1. I experience physical
discomfort or pain due to lack
of sleep caused by insomnia.
2. My insomnia leads to
fatigue and low energy levels
throughout the day.
3. Insomnia affects my ability
to engage in physical
activities or exercise.
4. I believe that improving my
sleep quality would positively
impact my physical health.
5. Insomnia negatively
impacts my overall physical
well-being.
6. Developing good sleep
habits and routines is
important for maintaining my
physical health.
7. How strongly do you agree
that experiencing insomnia
affects your overall physical
health?
8. To what extent do you
believe that insomnia
negatively impacts your
immune system and makes
you more susceptible to
illness?
9. Do you agree that
insomnia leads to reduced
energy levels and decreased
productivity throughout the
day?
10. The physical symptoms of
insomnia (e.g., headaches,
muscle tension) negatively
impact my daily life.

The Effects of Insomnia on Strongly Agree Neutral Disagree Strongly

 Survey Questionnaire

my Mental Health Agree Disagree

1. To what extent do you agree
that difficulty falling asleep
contributes to increased levels
of stress and anxiety?
2. How strongly do you agree
that insomnia negatively
affects your mood and
emotional well-being?
3. To what extent do you agree
that insomnia leads to
difficulties in concentration and
focus during school hours?
4. Do you agree that insomnia
affects your overall mental
health and psychological well-
being?
5. To what extent do you agree
that insomnia increases
feelings of irritability and
frustration?
6. How strongly do you agree
that insomnia contributes to a
decreased sense of motivation
and engagement in daily
activities?
7. To what extent do you agree
that insomnia affects your
ability to cope with stressful
situations?
8. Do you agree that insomnia
leads to feelings of fatigue and
exhaustion during the day?
9. To what extent do you agree
that insomnia disrupts your
ability to relax and unwind after
a long day?
10. How strongly do you agree
that insomnia impacts your
overall quality of life and well-
being?