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Emotional Health & Sleep
Instructions:
The questions below ask about your feelings and thoughts during the last month.
For each question, choose how often you felt or thought a certain way.
In the last month, how often have you been upset because something that happened unexpectedly?
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In the last month, how often have you felt that you were unable to control the important things in your life?
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In the last month, how often have you felt nervous and "stressed"?
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In the last month, how often have you felt confident about your ability to handle your personal problems? (Reverse scored)
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In the last month, how often have you felt that things were going your way? (Reverse scored)
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In the last month, how often have you found that you could not cope with all the things that you had to do?
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In the last month, how often have you been able to control irritations in your life? (Reverse scored)
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In the last month, how often have you felt that you were on top of things?
(Reverse scored)
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In the last month, how often have you been angered because of things that were outside of your control?
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In the last month, how often have you felt difficulties were piling up so high that you could not overcome them?
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Sleep Screening
The following questions relate to your usual sleep habits during the past month. Answer all questions as accurately as you can.
Pittsburgh Sleep Quality Index (PSQI)
Sleep Timing and Duration
When have you usually gone to bed?
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Time:
How long (in minutes) has it usually taken you to fall asleep each night?
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Minutes:
When have you usually gotten up in the morning?
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Time:
How many hours of actual sleep do you get at night? (This may be different from
the number of hours you spend in bed.)
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Hours:
Sleep Disturbances
How often during the past month have you had trouble sleeping because you…
Cannot get to sleep within 30 minutes
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Wake up in the middle of the night or early morning
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Have to get up to use the bathroom
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Cannot breathe comfortably
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Cough or snore loudly
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Feel too cold
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Feel too hot
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Have bad dreams
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Have pain
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Other reasons (please specify):
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Sleep Medication Use
How often have you taken medicine (prescribed or over-the-counter) to help you sleep?
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Daytime Dysfunction
How often have you had trouble staying awake while driving, eating meals, or
engaging in social activity?
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How much of a problem has it been for you to keep up enthusiasm to get things
done?
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Overall Sleep Quality
During the past month, how would you rate your overall sleep quality?
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Emotional Regulation Screening
Please indicate how often each statement applies to you.
Answer based on how you typically behave, not just during a single event.
Difficulties in Emotion Regulation Scale – Short Form (DERS-SF)
I am clear about my feelings. (Reverse scored)
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I pay attention to how I feel. (Reverse scored)
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I experience my emotions as overwhelming and out of control.
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I have difficulty making sense out of my feelings.
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I am accepting of my emotional responses. (Reverse scored)
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When I’m upset, I have difficulty concentrating.
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When I’m upset, I have difficulty controlling my behaviors.
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I am attentive to my feelings. (Reverse scored)
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When I’m upset, I believe that I will remain that way for a long time.
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When I'm upset, I have difficulty thinking about anything else.
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When I'm upset, I become out of control.
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I believe that emotions are valid and understandable. (Reverse
scored)
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When I’m upset, I have difficulty focusing on other things.
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When I’m upset, I take actions that I later regret.
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When I'm upset, it takes me a long time to feel better.
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When I'm upset, I have difficulty planning tasks.
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When I'm upset, I have difficulty controlling my impulses.
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When I'm upset, I believe that I'll end up feeling very depressed.
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Self Esteem Screening
Below is a list of statements.
Please read each statement carefully and indicate how strongly you agree or disagree.
Rosenberg Self-Esteem Scale (RSES)
I feel that I am a person of worth, at least on an equal basis with
others.
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I feel that I have a number of good qualities.
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All in all, I am inclined to feel that I am a failure. (Reverse scored)
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I am able to do things as well as most other people.
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I feel I do not have much to be proud of. (Reverse scored)
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I take a positive attitude toward myself.
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On the whole, I am satisfied with myself.
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I wish I could have more respect for myself. (Reverse scored)
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I certainly feel useless at times. (Reverse scored)
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At times I think I am no good at all. (Reverse scored)
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