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Please Answer All Questions

The Insomnia Severity Index has seven questions. The seven answers are added up to get a total score. Please use the scale that follows the questions to determine your score.

Please rate the CURRENT (LAST 2 WEEKS) SEVERITY of your insomnia problem. Use the information at the bottom of the form to determine your score.

General information
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  2. (valid email required)
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Insomnia Problem
  1. Difficulty falling asleep
  2. Difficulty staying asleep
  3. Problems waking up too early
Additional Questions
  1. How SATISFIED/DISSATISFIED are you with your CURRENT sleep pattern?
  2. How NOTICABLE to others do you think your sleep problem is in terms of impairing the quality of your life?
  3. How WORRIED/DISTRESSED are you about your current sleep problem?
  4. To what extent do you consider your sleep problem to INTERFERE with your daily functioning (e.g. daytime fatique, mood, ability to function at work/daily chores, concentration, memory, etc.) CURRENTLY
Use the scale below to determine your score.

Use the following scale to determine your score:

  • Score 0 if you answered None, Very Satisfied or Not at all
  • Score 1 if you answered Mild, Satisfied or A little
  • Score 2 if you answered Moderate, Moderately Satisfied or Somewhat
  • Score 3 if you answered Severe, Dissatisfied or Much
  • Score 4 if you answered Very Severe, Very Dissatisfied or Very much