Insomnia Test Insomnia Test First Name* Last Name* Email Address* Phone Number* City Terms and Conditions*Before You BeginThe following questions serve as a preliminary assessment to ascertain if you need medical attention. These will take only a few minutes. Please answer as honestly as possible.How difficult do you find falling asleep?This question is related to the quality of your sleep Not difficult at all Not really difficult Moderately difficult Difficult Very difficult How difficult do you find staying asleep? Do you wake up often during the night?This question is related to the quality of your sleep Not difficult at all Not really difficult Moderately difficult Difficult Very difficult How difficult do you find waking up in the morning?This question is related to the quality of your sleep Not difficult at all Not really difficult Moderately difficult Difficult Very difficult How difficult do you find waking up in the morning?This question is related to the quality of your sleep Not difficult at all Not really difficult Moderately difficult Difficult Very difficult How satisfied/ dissatisfied are you with your current (the past two weeks) sleep pattern?This question is related to the impact of insomnia on your life Very Satisfied Satisfied Moderately satisfied Dissatisfied Very Dissatisfied To what extent is your current sleep problem noticeable to others and impacting your quality of life?This question is related to the impact of insomnia on your life Not at all noticeable A little Somewhat Much Very much noticeable How worried/distressed are you about your current sleep problem?This question is related to the impact of insomnia on your life Not at all worried A Little Somewhat Much Very much worried How much is your current sleep problem interfering with their daily life (fatigue, mood, concentration, memory, etc...)?This question is related to the impact of insomnia on your life Not at all interfering A Little Somewhat Much Very much Feeling nervous, anxious or on edgeOver the last 2 weeks, how often have you been bothered by the following problems? Not at all Several Days More than half the days Nearly every day Not being able to stop or control worryingOver the last 2 weeks, how often have you been bothered by the following problems? Not at all Several Days More than half the days Nearly every day Worrying too much about different thingsOver the last 2 weeks, how often have you been bothered by the following problems? Not at all Several Days More than half the days Nearly every day Trouble relaxingOver the last 2 weeks, how often have you been bothered by the following problems? Not at all Several Days More than half the days Nearly every day Being so restless that it is hard to sit stillOver the last 2 weeks, how often have you been bothered by the following problems? Not at all Several Days More than half the days Nearly every day Becoming easily annoyed or irritatedOver the last 2 weeks, how often have you been bothered by the following problems? Not at all Several Days More than half the days Nearly every day Feeling afraid as if something awful might happenOver the last 2 weeks, how often have you been bothered by the following problems? Not at all Several Days More than half the days Nearly every day If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?Over the last 2 weeks, how often have you been bothered by the following problems? Not difficult at all Somewhat difficult Very difficult Extremely difficult When did the symptoms begin? Time is Up! Time's up
