Insomnia Sleep Questionnaire
Name :
Age :
Gender:
semester:
1. Are you hostelite?
a. Yes
b. No
2. Please
None Mild Moderate Severe Very
mark the
0
1
severe
severity of
your
insomnia.
a. Trouble in
falling
sleep
b. Trouble in
staying
sleep
c. Waking up
too early
3. You have a chronic stress problem
a. Yes
b. No
4. Are you satisfied/dissatisfied with your current sleep pattern?
a. Yes
b. No
5. To what extent do you consider your sleep problem interrupt with your Not at
all routine work(e.g., mode, study, memory, concentration.)?
a. Not at all interrupting
b. Little
c. Somewhat
d. Much
Insomnia Sleep Questionnaire
e. Very much interrupting
6. Sleep during night
a. doesn’t wake at up night
b. I can’t sleep during night
c. I wake up at least once a night, but go back to sleep easily
d. I wake up more than once a night and stay whole night
7. Are you feel sad or depressed when you can’t sleep properly?
a. Yes
b. No
8. Are you feel frustrated?
a. Yes
b. No
9. Concentration or decision-making problems;
a. Sleep can’t affect my concentration
b. Sleep may affect my concentration level
c. Depends on condition of mood
d. Improper sleep affect on my concentration
10.is sleep impact on your body weight when you can’t take your sleep properly
for months
a. increase
b. decrease
c. none
11.If you are insomniac person, you have noticed any impact on your body
weight.
a. Increase
b. Decrease
c. None.
12. Is improper sleep effect on your digestion.
a. Yes
b. No
13.You feel anxiety or depression or both when you can’t take your sleep
properly for few days or month
a. Yes
b. No
14.If you are taking improper sleep for months or days, has you felt any change
in your mood.
a. Yes
b. No
Insomnia Sleep Questionnaire