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Home
About
About David
Sleep Speaker
Clinic
Attend Appointment
About the Clinic
Telehealth Consultations
Sleep Studies
Questionnaires & forms
Registration form
Prescription requests
FAQs
About Sleep
SleepHub
Sleep Research
Contact
Insomnia Severity Index
Full Name
(Required)
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
(Required)
None
Mild
Moderate
Severe
Very Severe
Difficulty staying asleep
(Required)
None
Mild
Moderate
Severe
Very Severe
Problems waking up too early
(Required)
None
Mild
Moderate
Severe
Very Severe
How SATISFIED / DISSATISFIED are you with your CURRENT sleep pattern?
(Required)
Very Satisfied
Satisfied
Moderately Satisfied
Dissatisfied
Very Dissatisfied
How NOTICEABLE to others do you think your sleep problem is in terms of impairing the quality of your life?
(Required)
Not at all Noticeable
A Little
Somewhat
Much
Very Much Noticeable
How WORRIED/DISTRESSED are you about your current sleep problem?
(Required)
Not at all Worried
A Little
Somewhat
Much
Very Much Worried
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?
(Required)
Not at all Interfering
A Little
Somewhat
Much
Very Much Interfering
Results
Total Score
Total score categories:
0–7 = No clinically significant insomnia 8–14 = Subthreshold insomnia 15–21 = Clinical insomnia (moderate severity) 22–28 = Clinical insomnia (severe)
Send a copy
Enter email address if you would like a copy of the completed questionnaire.
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