For each question, please select the number that best describes your answer.

Please rate the CURRENT (i.e. LAST 2 WEEKS) SEVERITY of your insomnia problem(s).
Difficulty falling asleep
Difficulty staying asleep
Problems waking up too early
How SATISFIED / DISSATISFIED are you with your CURRENT sleep pattern?
How NOTICEABLE to others do you think your sleep problem is in terms of impairing the quality of your life?
How WORRIED/DISTRESSED are you about your current sleep problem?
To what extent do you consider your sleep problem to INTERFERE with your daily functioning (e.g. daytime fatigue, mood, ability to function at work/daily chores, concentration, memory, mood, etc.) CURRENTLY?
Total score categories:
0–7 = No clinically significant insomnia
8–14 = Subthreshold insomnia
15–21 = Clinical insomnia (moderate severity)
22–28 = Clinical insomnia (severe)