1 UNIVERSITY OF MICHIGAN SLEEP DISORDERS CENTER QUESTIONNAIRE INSTRUCTIONS The quesons in this booklet will help us understand your sleep/wake problems. Please answer each queson as completely and as accurately as possible. Answers to these quesons will be kept confiden- al. Some quesons might be beer answered by your spouse, bed-partner, parent, or roommate. Please ask for help from such a person if appropriate. Do not spend too much me on any queson. Your first impression is generally the best. The me period of all quesons is THE PRESENT (which includes THE LAST 6 MONTHS) unless other- wise specified. A “WEEKDAY” is any day on which you normally work. For most people, it is Monday-Friday. Howev- er, if you are engaged in shiſt work, or have an unusual schedule, then “DAYTIME” AND “NIGHTTIME” re- fer to your own major waking and sleeping periods. Many of the quesons begin with “HOW OFTEN….”, and five choices are offered. These should be an- swered by circling the appropriate number: Please list your: NAME:____________________________________ UM 9-digit MRN#:____________________________ Birthdate: _________________________________ Today’s date: ______________________________ Now please turn the page—REMEMBER, the quesons are on BOTH SIDES of the page. Never or almost never 1 Seldom Not more than once per month 2 Occasionally 1-3 mes per month 3 Oſten More than 1-2 mes per week 4 Always or Almost always or almost everyday 5
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UNIVERSITY OF MI HIGAN SLEEP DISORDERS ENTER QUESTIONNAIRE€¦ · SLEEP DISORDERS ENTER QUESTIONNAIRE INSTRUTIONS The questions in this booklet will help us understand your sleep/wake
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1
UNIVERSITY OF MICHIGAN SLEEP DISORDERS CENTER
QUESTIONNAIRE
INSTRUCTIONS
The questions in this booklet will help us understand your sleep/wake problems. Please answer each
question as completely and as accurately as possible. Answers to these questions will be kept confiden-
tial. Some questions might be better answered by your spouse, bed-partner, parent, or roommate.
Please ask for help from such a person if appropriate. Do not spend too much time on any question.
Your first impression is generally the best.
The time period of all questions is THE PRESENT (which includes THE LAST 6 MONTHS) unless other-
wise specified.
A “WEEKDAY” is any day on which you normally work. For most people, it is Monday-Friday. Howev-
er, if you are engaged in shift work, or have an unusual schedule, then “DAYTIME” AND “NIGHTTIME” re-
fer to your own major waking and sleeping periods.
Many of the questions begin with “HOW OFTEN….”, and five choices are offered. These should be an-
swered by circling the appropriate number:
Please list your: NAME:____________________________________
UM 9-digit MRN#:____________________________
Birthdate: _________________________________
Today’s date: ______________________________
Now please turn the page—REMEMBER, the questions are on BOTH SIDES of the page.
Never or
almost never
1
Seldom
Not more than
once per month
2
Occasionally
1-3 times per
month
3
Often
More than 1-2
times per week
4
Always or
Almost always or
almost everyday
5
2
1. Do you feel that you have insomnia..………………………………………………………………………….
If yes, for how many years have you had insomnia?.................................................
2. Do you feel that you are excessively sleepy?....................................................................
If yes, for how many years have you been excessively sleepy? ……………………………..
3. What time do you usually go to bed:
On weekdays?............................................................................................................
On weekends?............................................................................................................
4. What time do you usually get up:
On weekdays?............................................................................................................
On weekends?............................................................................................................
5. How long does it usually take you to fall asleep after deciding to go to sleep?................
6. What is the total number of hours of sleep that you usually get at night? (Do not
include time that you spend awake in bed during the night)…………………………………..
7. How many times do you wake up during a typical night’s sleep?....................................
8. How many times do you get out of bed during a typical night’s sleep?...........................
9. How long does it usually take you to “get going” after you get out of bed?...................
10. How many naps do you take on purpose in a usual weekday?......................................
11. What is the total amount of sleep that you get during naps in a usual weekday?.......
Yes NO
_____ Years
Yes No
_____ Years
_____
_____
AM
PM
_____
_____
AM
PM
_____
_____
AM
PM
_____
_____
AM
PM
_____hr _____min
_____hr
_____min
_____
_____
_____hr _____min
_____
_____hr _____min
HOW OFTEN do you :
12. - have difficulty getting to sleep at night?.......................................................................... 1 2 3 4 5
13. - have restless legs (crawling or aching feelings and inability to keep your legs still)
When trying to get to sleep?......................................................................................... 1 2 3 4 5
14. - have leg cramps (Charlie horses) at night?....................................................................... 1 2 3 4 5
15. - paraesthesias (pins and needles feelings) in your hands, arms, legs, or feet at night?... 1 2 3 4 5
16. - have a poor night’s sleep?............................................................................................... 1 2 3 4 5
17. - have irregular sleep habits (more than 4 hours different from your usual bedtime
And wake-up time)?...................................................................................................... 1 2 3 4 5
1 = Never 2 = Seldom 3 = Occasionally 4 = Often 5 = Almost always
3
HOW OFTEN do you….
18. - work nights?...................................................................................................... 1 2 3 4 5
19. - have restless, disturbed sleep or disturb the sleep of your bed partner? ....... 1 2 3 4 5
20. - snore in any way?............................................................................................. 1 2 3 4 5
1. Where are you completing this questionnaire? (check one and if “other” please describe)
______ Sleep Laboratory
______ Sleep or Neurology Clinic
______ Other Location ______________________________
2. Sex: ______ Male
______ Female
3. Your Occupation: ___________________________________________
______ Full Time
______ Part Time
4. Do you drive a motor vehicle?
______ No ______ Yes, I drive: _____Daily
_____ Several days a week
_____ Two or fewer days a week
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MEDICAL OUTCOME
INSTRUCTIONS: Answer every question by checking the appropriate box, 1, 2, 3, etc. If you are unsure
about how to answer a question, please give the best answer you can. CHECK ONE BOX
1. In general, would you say your health is:
1 Excellent 2Very good 3Good 4 Fair 5 Poor
2. Compared to one year ago, how would you rate your health in general now?
1 Much better now than one year ago 4 Somewhat worse now than one year ago
2 Somewhat better now than one year ago 5 Much worse now than one year ago
3 About the same
3. The following questions are about activities you might do during a typical day. During the past 8 weeks
has your health limited you in these activities? If so how much? Check one box on each line.
Yes, Limited
A lot
Yes, Limited A little
No, not limited at all
a. Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports
1 2 3
b. Moderate activities such as moving a table, pushing a vacuum cleaner, bowling, or playing golf
1 2 3
c. Lifting or carrying groceries 1 2 3
d. Climbing several flights of stairs 1 2 3
E. Climbing one flight of stairs 1
2 3
f. Bending, kneeling, or stooping 1 2 3
g. Walking more than a mile 1 2 3
h. Walking several blocks 1 2 3
i. Walking one block 1 2 3
J. Bathing and dressing yourself 1 2 3
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4. During the past 8 weeks, have you had any of the following problems with your work or other regular daily activities as a result of your physical health? (Please answer yes or no by checking the appropriate box).
5. During the past 8 weeks, have you had any of the following problems with your work or other regular daily activities as a result of any emotional problems (such as feeling depressed or anxious)? (Please an-swer yes or no by checking the appropriate box).
6. During the past 8 weeks, to what extent has your physical health or emotional problems interfered with your normal social activities with family, friends, neighbors, or groups? (check one box)
7. How much bodily pain have you had during the past 8 weeks? (check one box)
8. During the past 8 weeks, how much did pain interfere with your normal work (including work both out-side the home and housework)? (check one box)
9. These questions are about how you feel and how things have been with you during the past 8 weeks. For each question, please indicate the one answer that comes closest to the way you have been feeling. (check one box on each line).
a. Cut down on the amount of time you spent on work or other activities
o No 1 Yes
b. Accomplished less than you would like 1 Yes o No
c. Were limited in the kind of work or other activities 1 Yes o No
d. Had difficulty performing work or other activities 1 Yes o No
a. Cut down on the amount of time spent on work or other activities
1 Yes o No
b. Accomplished less than you would like 1 Yes o No
c. Didn’t do work or other activities as carefully as usual 1 Yes o No
1 Not at all 2 Slightly 3 Moderately 4 Quite a bit 5 Extremely
1 None 2 Very Mild 3 Mild 4 Moderate 5 Severe 6 Very Severe
1 Not at all 2 Slightly 3 Moderately 4 Quite a bit 5 Extremely
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How much of the time during the
past 8 weeks
All of the
Time
Most of
the Time
A good
bit of
the Time
Some
of the
Time
A Little
of the
Time
None
of the
Time
a. did you feel full of pep? 1 2 3 4 5 6
b. have you been a very nervous person? 1 2 3 4 5 6
c. have you felt so down in the dumps
nothing could cheer you up ?
1
2
3
4
5
6
d. have you felt calm and peaceful? 1 2 3 4 5 6
e. did you have a lot of energy? 1 2 3 4 5 6
f. have you felt downhearted and blue? 1 2 3 4 5 6
g. did you feel worn out? 1 2 3 4 5 6
h. have you been a happy person? 1 2 3 4 5 6
i. did you feel tired? 1 2 3 4 5 6
J. has your health limited your social activi
ties ( like visiting with friends or close
relatives)?
1
2
3
4
5
6
Definitely True
Mostly True
Not Sure
Mostly False
Definitely False
a. I seem to get sick a little easier than other
people.
1
2
3
4
5
b. I am as healthy as anybody I know.
1
2
3
4
5
c. I expect my health to get worse.
1
2
3
4
5
d. My health is excellent.
1
2
3
4
5
10. Please choose the answer that best describes how true or false each of the following statements is