Note: Please enter your
closest approximation of your usual bedtime and wake time
Please list any prescribed medications (if none, leave blank)
Please tick all that apply to you
Did or does your mother/father or brother/sister suffer from:
(please tick any applicable answers)
If you have a current partner, if possible, please
make sure they are here with you to complete this section
Note: This is to be completed by the patient's partner, based on how
they perceive the patient's level of sleepiness.
The remainder of this questionnaire can be completed by the patient
and no longer requires the patient's partner.
Note: This is to be completed by the patient, about themselves.
The following questions ask about how you have been feeling over the last two weeks. Please mark the box which is closest to how you have been feeling.
For each question, please rate the current severity of your sleep
problem by selecting the most appropriate response from the drop down list.