The following questions are related to your sleep during the past few months.
Weekdays
* When do you usually go to sleep?
1 am
2 am
3 am
4 am
5 am
6 am
7 am
8 am
9 am
10 am
11 am
Noon
1 pm
2 pm
3 pm
4 pm
5 pm
6 pm
7 pm
8 pm
9 pm
10 pm
11 pm
Midnight
* When do you usually wake up?
1 am
2 am
3 am
4 am
5 am
6 am
7 am
8 am
9 am
10 am
11 am
Noon
1 pm
2 pm
3 pm
4 pm
5 pm
6 pm
7 pm
8 pm
9 pm
10 pm
11 pm
Midnight
* When do you usually go to sleep?
1 am
2 am
3 am
4 am
5 am
6 am
7 am
8 am
9 am
10 am
11 am
Noon
1 pm
2 pm
3 pm
4 pm
5 pm
6 pm
7 pm
8 pm
9 pm
10 pm
11 pm
Midnight
* When do you usually wake up?
1 am
2 am
3 am
4 am
5 am
6 am
7 am
8 am
9 am
10 am
11 am
Noon
1 pm
2 pm
3 pm
4 pm
5 pm
6 pm
7 pm
8 pm
9 pm
10 pm
11 pm
Midnight
* How many hours do you try to sleep?
less than 3
4-6
7
8
9
10-12
greater than 12
* How long do you actually sleep?
less than 3
4-6
7
8
9
10-12
greater than 12
How satisfied are you with your… (1 = Very Satisfied, 7 = Very Dissatisfied)
How often do you (or your bed partner/roommate) find that you:
* Have others say that you stop breathing in your sleep
Never
Rarely
Sometimes
Often
Usually
Always