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 sleepNot difficult at allNot really difficultModerately difficultDifficultVery difficultHow difficult do you find staying asleep? Do you wake up often during the night?This question is related to the quality of your sleepNot difficult at allNot really difficultModerately difficultDifficultVery difficultHow difficult do you find waking up in the morning?This question is related to the quality of your sleepNot difficult at allNot really difficultModerately difficultDifficultVery difficultHow difficult do you find waking up in the morning?This question is related to the quality of your sleepNot difficult at allNot really difficultModerately difficultDifficultVery difficultHow satisfied/ dissatisfied are you with your current (the past two weeks) sleep pattern?This question is related to the impact of insomnia on your lifeVery SatisfiedSatisfiedModerately satisfiedDissatisfiedVery DissatisfiedTo 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 lifeNot at all noticeableA littleSomewhatMuchVery much noticeableHow worried/distressed are you about your current sleep problem?This question is related to the impact of insomnia on your lifeNot at all worriedA LittleSomewhatMuchVery much worriedHow 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 lifeNot at all interferingA LittleSomewhatMuchVery muchFeeling nervous, anxious or on edgeOver the last 2 weeks, how often have you been bothered by the following problems?Not at allSeveral DaysMore than half the daysNearly every dayNot being able to stop or control worryingOver the last 2 weeks, how often have you been bothered by the following problems?Not at allSeveral DaysMore than half the daysNearly every dayWorrying too much about different thingsOver the last 2 weeks, how often have you been bothered by the following problems?Not at allSeveral DaysMore than half the daysNearly every dayTrouble relaxingOver the last 2 weeks, how often have you been bothered by the following problems?Not at allSeveral DaysMore than half the daysNearly every dayBeing 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 allSeveral DaysMore than half the daysNearly every dayBecoming easily annoyed or irritatedOver the last 2 weeks, how often have you been bothered by the following problems?Not at allSeveral DaysMore than half the daysNearly every dayFeeling afraid as if something awful might happenOver the last 2 weeks, how often have you been bothered by the following problems?Not at allSeveral DaysMore than half the daysNearly every dayIf 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 allSomewhat difficultVery difficultExtremely difficultWhen did the symptoms begin?Time is Up!
