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Sleep Screening
Pittsburgh Sleep Quality Index (PSQI)
Instructions: The following questions relate to your usual sleep habits during the past month. Answer all questions as accurately as you can.
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
*
Cough or snore loudly
*
Feel too cold
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Feel too hot
*
Have bad dreams
*
Have pain
*
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?
*
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?
*
Overall Sleep Quality
During the past month, how would you rate your overall sleep quality?
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Submit