Psychological Sleep Services Sleep Assessment

Name ________________ Date __________

****************************************************

Insomnia Severity Index

For each question, please CIRCLE the number that best describes your answer.

Please rate the CURRENT (i.e. LAST 2 WEEKS) SEVERITY of your insomnia problem(s).

Insomnia problem None Mild Moderate Severe Very severe

1. Difficulty falling asleep 0 1 2 3 4

2. Difficulty staying asleep 0 1 2 3 4

3. Problem waking up too early 0 1 2 3 4

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

Very Satisfied Moderately Dissatisfied Very

Satisfied Satisfied Dissatisfied
0 1 2 3 4

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

Not at all A Little Somewhat Much Very Much Noticeable

Noticeable
0 1 2 3 4

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

Not at all A Little Somewhat Much Very Much Worried

Worried
0 1 2 3 4

7. 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,
mood, etc.) CURRENTLY?

Not at all A Little Somewhat Much Very Much Interfering

Interfering
0 1 2 3 4
 THE EPWORTH SLEEPINESS SCALE

Name:

Today’s Date:

How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired?
This refers to your usual way of life in the past week. Even if you have not done some of these things
recently try to work out how they would have affected you. Use the following scale to choose the most
appropriate number for each situation:

0 = would never doze

1 = slight chance of dozing
2 = moderate chance of dozing
3 = high chance of dozing

Situation Chance of Dozing

Sitting and reading

Watching TV

Sitting, inactive in a public place (e.g. a theater or a meeting)

As a passenger in a car for an hour without a break

Lying down to rest in the afternoon when circumstances permit

Sitting and talking to someone

Sitting quietly after a lunch without alcohol

In a car, while stopped for a few minutes in the traffic

 Beliefs About Sleep

Several statements reflecting people’s beliefs and attitudes about sleep are listed below. Please indicate (by
circling the number) to what extent you personally agree or disagree with each statement. There is no right or
wrong answer. For each statement, circle a number that best reflects your personal experience. Consider the
whole scale, rather than only the extremes of the continuum.

1. I need 8 hours of sleep to feel refreshed and Strongly Strongly

0 1 2 3 4 5 6 7 8 9 10
function well during the day. Disagree Agree

2. When I do not get proper amount of sleep on Strongly Strongly

0 1 2 3 4 5 6 7 8 9 10
a given night, I need to catch up on the next Disagree Agree
day by napping or on the next night by
sleeping longer.
3. I am concerned that chronic insomnia may Strongly Strongly
0 1 2 3 4 5 6 7 8 9 10
have serious consequences for my physical Disagree Agree
health.
4. I am worried that I may lose control over my Strongly Strongly
0 1 2 3 4 5 6 7 8 9 10
abilities to sleep. Disagree Agree

5. After a poor night’s sleep, I know that it will Strongly Strongly

interfere with my daily activities on the next day. Disagree
0 1 2 3 4 5 6 7 8 9 10
Agree

6. In order to be alert and function well during Strongly Strongly

0 1 2 3 4 5 6 7 8 9 10
the day, I am better off taking a sleeping pill Disagree Agree
rather than having a poor night’s sleep.
7. When I feel irritable, depressed, or anxious Strongly Strongly
0 1 2 3 4 5 6 7 8 9 10
during the day, it is mostly because I did not Disagree Agree
sleep well the night before.
8. When I sleep poorly on one night, I know that Strongly Strongly
0 1 2 3 4 5 6 7 8 9 10
it will disturb my sleep schedule for the whole Disagree Agree
week.
9. Without an adequate night’s sleep, I can Strongly Strongly
0 1 2 3 4 5 6 7 8 9 10
hardly function the next day. Disagree Agree

10. I can’t ever predict whether I will have a good Strongly Strongly
0 1 2 3 4 5 6 7 8 9 10
or poor night’s sleep. Disagree Agree

11. I have little ability to manage the negative Strongly Strongly

0 1 2 3 4 5 6 7 8 9 10
consequences of disturbed sleep. Disagree Agree

12. When I feel tired, have no energy, or just Strongly Strongly

0 1 2 3 4 5 6 7 8 9 10
seem not to function well during the day, it is Disagree Agree
generally because I did not sleep well the
night before.
13. I believe that insomnia is essentially a result Strongly Strongly
0 1 2 3 4 5 6 7 8 9 10
of a chemical imbalance. Disagree Agree

14. I feel that insomnia is ruining my ability to Strongly Strongly

0 1 2 3 4 5 6 7 8 9 10
enjoy life and prevents me from doing what I Disagree Agree
want.
15. Medication is probably the only solution to Strongly Strongly
0 1 2 3 4 5 6 7 8 9 10
sleeplessness. Disagree Agree

16. I avoid or cancel obligations (social, family, Strongly Strongly

0 1 2 3 4 5 6 7 8 9 10
occupational) after a poor night’s sleep. Disagree Agree
 Morningness/Eveningness
Directions: For each item, please check one response that best describes you.
1. Considering only your own “feeling best” rhythm,
at what time would you get up if you were entirely
free to plan your day?
__ a.(5) 5:00-6:30 a.m.
__ b.(4) 6:30-7:45 a.m.
__ c.(3) 7:45—9:45 a.m.
__ d.(2) 9:45-11:00 a.m.
__ e.(1) 11:00 a.m. – 12:00 noon
2. Considering only your own “feeling best” rhythm,
at what time would you go to bed if you were
entirely free to plan your evening?
__ a.(5) 8:00 - 9:00 p.m.
__ b.(4) 9:00 - 10:15 p.m.
__ c.(3) 10:15 p.m.- 12:30 a.m.
__ d.(2) 12:30 - 1:45 a.m.
__ e.(1) 1:45 a.m. – 3:00 a.m.
3. Assuming normal circumstances, how easy do
you find getting up in the morning?
__ a.(1) Not at all easy
__ b.(2) Slightly easy
__ c.(3) Fairly easy
__ d.(4) Very easy
4. How alert do you feel after the first half hour after
having awakened in the morning?
__ a.(1) Not at all alert
__ b.(2) Slightly alert
__ c.(3) Fairly alert
__ d.(4) Very alert
5. During the first half hour after having awakened in
the morning, how tired do you feel?
__ a.(1) Very tired
__ b.(2) Fairly tired
__ c.(3) Slightly tired
__ d.(4) Not at all tired
6. You have decided to engage in some physical
exercise. A friend suggests that you do this one
hour twice a week and the best time for him is
7:00-8:00 am. Bearing in mind nothing else but
your “feeling best” rhythm, how do you think you
would perform?
__ a.(4) Would be in good form
__ b.(3) Would be in reasonable form
__ c.(2) Would find it difficult
__ d.(1) Would find it very difficult
7. At what time in the evening do you feel tired and as
a result, in need of sleep?
__ a.(5) 8:00 -9:00 p.m.
__ b.(4) 9:00 - 10:15 p.m.
__ c.(3) 10:15 p.m. – 12:30 a.m.
__ d.(2) 12:30 - 1:45 a.m.
__ e.(1) 1:45 a.m. – 3:00 a.m.
8. You wish to be at your peak performance for a test,
which you know is going to be mentally exhausting
and lasting for two hours. You are entirely free to
plan your day, and considering only your own”
feeling best” rhythm, which ONE of the four testing
times would you choose?
__ a.(4) 8:00 - 10:00 a.m.
__ b.(3) 11:00 a.m. - 1:00 p.m.
__ c.(2) 3:00 - 5:00 p.m.
__ d.(1) 7:00-9:00 p.m.
9. One hears about “morning” and ”evening” type
people. Which ONE of these types do you consider
yourself to be?
__ a.(4) Definitely a morning type
__ b.(3) More a morning than an evening type
__ c.(2) More an evening than a morning type
__ d.(1) Definitely an evening type
10. When would you prefer to rise (provided you have
a full day’s work – 8 hours) if you were totally free
to arrange your time?
__ a.(4) Before 6:30 a.m.
__ b.(3) 6:30 – 7:30 a.m.
__ c.(2) 7:30 - 8:30 a.m.
__ d.(1) 8:30 a.m. or later
11. If you always had to rise at 6:00 am, what do you
think it would be like?
__ a.(1) Very difficult and unpleasant
__ b.(2) Rather difficult and unpleasant
__ c.(3) A little unpleasant but no great problem
__ d.(4) Easy and not unpleasant
12. How long a time does it usually take before you
“recover your senses” in the morning after rising
from a night’s sleep?
__ a.(4) 0-10 minutes
__ b.(3) 11-20 minutes
__ c.(2) 21-40 minutes
__ d.(1) More than 40 minutes
13. Please indicate to what extent you are a morning
or an evening active individual?
__ a.(4) Very morning active (morning alert & evening
tired)
__ b.(3) To some extent, morning active
__ c.(2) To some extent, evening active
__ d.(1) Very evening active (morning tired &
evening alert)
 Sleep-Related Behaviours Questionnaire

Please carefully read each of the statements below and circle the number that best

Always/Almost
describes how often you do the following things in order to cope with tiredness or

Never/Almost

Sometimes
improve your sleep.

Rarely

Often
To cope with tiredness or improve sleep ...

1. I spend time considering ways to improve sleep 0 1 2 3 4

2. I stay in the background in social situations 0 1 2 3 4
3. I try to stop all thinking when trying to get to sleep 0 1 2 3 4
4. I do something active close to bedtime to tire myself out 0 1 2 3 4
5. I miss or cancel appointments (daytime or evening) 0 1 2 3 4
6. During the day, I block thoughts about sleep out of my mind 0 1 2 3 4
7. I reduce my expectations of what I can achieve 0 1 2 3 4
8. I figure out how I will catch up on my sleep later on 0 1 2 3 4
9. I work hard to conserve energy 0 1 2 3 4
10. I try to keep all disturbing thoughts and images out of my mind while in bed 0 1 2 3 4
11. I avoid talking about my sleep 0 1 2 3 4
12. I look at the clock on waking to calculate how many hours of sleep I got 0 1 2 3 4
13. I plan to get an early night 0 1 2 3 4
14. I give up trying to work 0 1 2 3 4
15. I take a sleeping pill or pills 0 1 2 3 4
16. I catch up on sleep by napping 0 1 2 3 4
17. I wear earplugs to block out all sounds that might wake me up/prevent me falling asleep 0 1 2 3 4
18. I worry about the consequences of poor sleep while lying in bed 0 1 2 3 4
19. I take on fewer social commitments 0 1 2 3 4
20. I put off tasks until tomorrow 0 1 2 3 4
21. I avoid difficult conversations with people 0 1 2 3 4
22. During the day, I conserve energy any way I can 0 1 2 3 4
23. I avoid sleeping away from home 0 1 2 3 4
24. I look at the clock to see how long it's taking to get to sleep 0 1 2 3 4
25. I am less active during the day 0 1 2 3 4
26. I keep busy to stop thinking about my sleep 0 1 2 3 4
27. I limit myself to mundane chores or tasks during the day/evening 0 1 2 3 4
28. I worry about other things (e.g., work) to distract from concerns about sleep 0 1 2 3 4
29. I take herbal remedies to aid sleep 0 1 2 3 4
30. While in bed, I try to block out thinking about any problems 0 1 2 3 4
31. I stick to a routine during the day so that I don't have to think as much 0 1 2 3 4
32. I give myself lots of time to fall asleep by going to bed early.$ 0 1 2 3 4
 SLEEP ENVIRONMENT QUESTIONNAIRE

1. I use an alarm clock five or more days a week.

_____ True _____ False _____ Not Applicable

2. I keep the temperature in the bedroom so cold that I have 2 or more blankets on the bed to stay
warm at night

_____ True _____ False _____ Not Applicable

3. The blinds and curtains in the bedroom are so effective that at sunrise the room is so dark its hard
to tell that the sun came up.

_____ True _____ False _____ Not Applicable

4. I have spent real time and money making sure that my mattress and pillow are perfect for me.

_____ True _____ False _____ Not Applicable

5. During the night, my bedroom is insulated so well that I rarely if ever hear outside noise from the
road, neighbors, etc.

_____ True _____ False _____ Not Applicable

6. House noise from the radiators, floor boards, etc. is so minimal that I am rarely aware of such
sounds.

_____ True _____ False _____ Not Applicable

7. My home is a safe place. My partner and/or pet insure and/or the locks and alarm system and/or
concern and support of my neighbors provide me a level of comfort such that I rarely if ever worry
about being safe at night.

_____ True _____ False _____ Not Applicable

8. On three or more nights per week, I engage in two or more of the following behaviors in the
bedroom: watch TV, read, plan, worry, work, clean, or eat).

_____ True _____ False _____ Not Applicable

9. My pets rarely if ever keep me from falling asleep or wake me up during the night.

_____ True _____ False _____ Not Applicable

10. My bed partner’s sleep schedule or “habits” while in bed (reading, moving about, stealing the
covers, snoring, etc.) rarely if ever disturb my sleep.

_____ True _____ False _____ Not Applicable

11. My child’s/children’s sleep schedule or “habits” while in bed or during the night rarely if ever
disturb my sleep.

_____ True _____ False _____ Not Applicable

 Glasgow Sleep Effort Scale

Broomfield, N., & Espie, C. (2005). Towards a valid, reliable measure of sleep effort.
Journal of Sleep Research, 14, 401-407.

The following seven statements relate to your night-time sleep pattern in the past week.
Please indicate by circling one response how true each statement is for you.

1 I put too much effort into sleeping when it should come naturally Very much To some extent Not at all

2 I feel I should be able to control my sleep Very much To some extent Not at all

3 I put off going to bed at night for fear of not being able to sleep Very much To some extent Not at all

4 I worry about not sleeping if I cannot sleep Very much To some extent Not at all

5 I am no good at sleeping Very much To some extent Not at all

6 I get anxious about sleeping before I go to bed Very much To some extent Not at all

7 I worry about the consequences of not sleeping Very much To some extent Not at all$

$
 Generalized*Anxiety*Disorder*73item*(GAD37)*scale*
*
*
Over*the*last*2*weeks,*how*often*have* Not$at$ Several$ Over$half$ Nearly$
you*been*bothered*by*the*following* all$sure$ days$ the$days$ every$day$
problems?**
*
1. Feeling$nervous,$anxious$or$on$edge$ 0$ 1$ 2$ 3$
2. Not$being$able$to$stop$or$control$ 0$ 1$ 2$ 3$
worrying$$
3. Worrying$too$much$about$different$ 0$ 1$ 2$ 3$
things$$
4. Trouble$relaxing$$ 0$ 1$ 2$ 3$
5. Being$so$restless$that$it$is$hard$to$sit$ 0$ 1$ 2$ 3$
still$$
6. Becoming$easily$annoyed$or$irritable$$ 0$ 1$ 2$ 3$
7. Feeling$afraid$as$if$something$awful$ 0$ 1$ 2$ 3$
might$happen$$
Column'total' $ $ $ $
Overall'total' $
$
$
$
If$you$checked$off$any$problems,$how$difficult$have$these$made$it$for$you$to$do$your$
work,$take$care$of$things$at$home,$or$get$along$with$other$people?$
$
Not$difficult$at$all$___________$
Somewhat$difficult$_________$
Very$difficult$________________$
Extremely$difficult$__________$
$

Developed$by$Drs.$Robert$L.$Spitzer,$Janet$B.W.$Williams,$Kurt$Kroenke$and$colleagues,$
with$an$educational$grant$from$Pfizer$Inc.$No$permission$required$to$reproduce,$
translate,$display$or$distribute.$$