Name
Which of the following is closest to the shifts you work?
Do you regularly have a bed partner? (3 or more days a week)

Please answer all of the following questions for what has been typical for you for the last 3 months.

1. My work or other activities prevent me from getting at least 7hrs of sleep
2. My bedtime or waketime varies by more than 3 hours
3. It takes me 30 minutes or more to fall asleep
4. I am awake for 30 minutes or more during the night
5. I wake up 30 or more minutes before I have to and can’t fall back asleep
6. I am tired, fatigued, or sleepy during the day
7. I sleep better if I go to bed before 9pm and wakeup up before 430am
8. I sleep better if I go to bed late (after 1am) and wakeup late (after 9am)
9. I am prone to fall asleep at inappropriate times or places
10. I snore
11. I wake up with a dry mouth in the morning (cotton mouth)
12. My snoring is so loud, that my bed partner complains
13. I have been told that that I stop breathing in my sleep
14. I wake up choking or gasping for air
15. I feel uncomfortable sensations in my legs, especially when sitting or lying down, that are relieved by moving them
16. I have an urge to move my legs that is worse in the evenings and nights
17. I wake up frequently during the night for no reason
18. When angered, humored, frightened, I experience sudden muscle weakness
19. When falling asleep or waking up, I experience scary dream like images
20. When I am first awakening, I feel like I can't move
21. I have nightmares
22. For no reason, I awaken suddenly, startled, and feeling afraid
23. I have been told that I walk, talk, eat, act strangely or violently when I sleep
24. I grind my teeth or clench your jaw during your sleep
25. My sleep difficulties interfere with my daily activities

Please rate the following based on your experiences in the last two weeks

I have difficulty falling asleep
I have difficulty staying asleep
I have problems with waking up too early
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 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, mood, etc.) CURRENTLY?