Insomnia Severity Index

Patient Name

Title

First name

Middle name

Surname

Maiden name (if applicable)

Date of Birth (DD/MM/YYYY)

Insomnia Severity Index (ISI)

For each question, please rate the current severity of your sleep problem by selecting the most appropriate response from the drop down list.

Please rate the severity of your difficulty in falling asleep:

Please rate the severity of your difficulty in staying asleep:

Please rate your problem waking up too early in the morning:

Please rate how SATISFIED you are with your current sleep pattern:

Please rate how your sleep problem INTERFERES with your daily functioning, i.e. daytime fatigue, concentration, mood, ability to function at work, ability to complete tasks at home, etc:

Please rate the extent to which your sleep problem is NOTICEABLE to others:

How WORRIED/DISTRESSED are you about your current sleep problem:

Additional Comments

Contact Information