17 Sleep

ID NUMBER:

FORM CODE: SLE VERSION: A 6/29/07

Contact Occasion

SEQ #

OMB#: 0925-XXXX

Exp. XX/XXXX

Public reporting burden for this collection of information is estimated to average 06 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-XXXX). Do not return the completed form to this address.

H

OMB#: 0925-XXXX

Exp. XX/XXXX

CHS/SOL Sleep Questionnaire

ID NUMBER:

FORM CODE: SLE VERSION: A 06/29/07

Contact Occasion

SEQ #

Acrostic:

Administrative Information

0a. Completion Date: // 0b. Staff ID:

Month Day Year

Instructions: Mark a check in the appropriate box for the response. Unless instructed, mark ONLY one response.

The following two questions refer to the times you get in and out of bed in order to sleep (not including naps).

1. What time do you usually go to bed?

a. On weekdays or work or school days? : __ __

am/pm

b. On weekends, or days off?             : __ __

am/pm

2. What time do you usually wake up?

a. On weekdays or work or school days? : __ __

am/pm

b. On weekends, or days off?             : __ __

am/pm

3. During a usual week, how many times do you nap for 5 minutes or more?

None 0

1 or more times 1

The next questions ask about your sleep habits. Please choose one of the answers for each of the following questions. Pick the answer that best describes how often you experienced the situation in the past 4 weeks.

No, not Yes, less Yes, 1 Yes, 3 Yes, 5 or

in the past than once or 2 times or 4 more times

4 weeks a week a week a week a week

4. Did you have trouble falling asleep? 1 2 3 4 5

5. Did you wake up several times at night? 1 2 3 4 5

6. Did you wake up earlier than you planned to? 1 2 3 4 5

7. Did you have trouble getting back to sleep

after you woke up too early? 1 2 3 4 5

8. Did you take sleeping pills to help you sleep? 1 2 3 4 5

9. Did you have sleep difficulties that made

you very irritable? 1 2 3 4 5

10. Did you feel overly sleepy during the day? 1 2 3 4 5

11. Overall, was your typical night’s sleep during the past 4 weeks:

Very sound or restful 0

Sound or restful 1

Average quality 2

Restless 3

Very restless 4

12. What is the chance that you would doze off or fall asleep (not just "feel tired") in each of the following situations? If you are never or rarely in the situation, please give your best guess for what would happen. (Choose one box for each item)

No Slight Moderate High

Chance Chance Chance Chance

a. Sitting and reading 1 2 3 4

b. Watching TV 1 2 3 4

c. Sitting inactive in a public place

(such as a theater or a meeting) 1 2 3 4

d. Riding as a passenger in a car for

an hour without a break 1 2 3 4

e. Lying down to rest in the afternoon

when circumstances permit 1 2 3 4

f. Sitting and talking to someone 1 2 3 4

g. Sitting quietly after a lunch without alcohol 1 2 3 4

h. In a car, while stopped for a few minutes in

traffic 1 2 3 4

i. At the dinner table 1 2 3 4

j. While driving 1 2 3 4

13. How often do you snore now? (Mark only one)

Never 1

Rarely (1-2 nights a week) 2

Sometimes (3-5 nights a week) 3

Always or almost always (6-7 nights a week) 4

Don’t know 9

14. How often do you have times when you stop breathing during your sleep?

Never 1

Rarely (1-2 nights a week) 2

Sometimes (3-5 nights a week) 3

Always or almost always (6-7 nights a week) 4

Don’t know 9

15. Do you ever experience a desire to move your legs because of discomfort or disagreeable sensations in your legs?

No 0  END QUESTIONNAIRE

Yes 1

Don’t know 9  END QUESTIONNAIRE

16. Do you sometimes feel the need to move to relieve the discomfort, for example by walking, or to relieve the discomfort by rubbing your legs?

No 0

Yes 1

Don’t know 9

17. Are these symptoms worse when you are at rest, with at least temporary relief by activity?

No 0

Yes 1

Don’t know 9

18. Are these symptoms worse later in the day or at night?

No 0

Yes 1

Don’t know 9

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