Please rate the CURRENT (last 2 weeks) SEVERITY of your insomnia problem(s).
1. Difficulty falling asleep: None Mild Moderate Severe Very Severe
2. Difficulty staying asleep: None Mild Moderate Severe Very Severe
3. Problems waking up too early: None Mild Moderate Severe Very Severe
4. How SATISFIED/DISSATISFIED are you with your CURRENT sleep pattern? Very Satisfied Satisfied Moderately Satisfied Dissatisfied Very Dissatisfied
5. How NOTICEABLE to others do you think your sleep problem is in terms of impairing the quality of your life? Not at all Noticeable A Little Somewhat Much Very Much Noticeable
6. How WORRIED/DISTRESSED are you about your CURRENT sleep problem? Not at all Worried A Little Somewhat Much Very Much Worried
7. To what extent do you consider your sleep problem to INTERFERE with your dailyfunctioning (e.g. daytime fatigue, mood, ability to function at work/daily chores, concentration, memory, etc.) CURRENTLY? Not at all Interfering A Little Somewhat Much Very Much Interfering
Your Initials:
Who should receive these results? Cancel Maj. Smith, LCSW Dr. Webb