Do you smoke?

Yes

No

Do you drink alcohol?

Yes

No

Do you consume tea, coffee or caffeinated beverages?

Yes

No

Do you take any recreational drugs?

Yes

No

Have you put on weight in the last year or so?

Yes

No

More or less than 5 kilograms

Yes

No

Are you a shift worker?

Yes

No

Were you a shift worker in the past?

Yes

No

Do you snore?

Every night

Sometimes

Never

Do you snore in all body positions?

Yes

No

Has anyone every told you that you stop breathing at night?

Yes

No

Do you wake up at night with a choking feeling?

Yes

No

Do you wake up at night with a dry mouth

Yes

No

Has your bed partner observed any sexual behaviours on your part, while you are asleep?

Yes

No

Has your sexual activity changed either while you are awake, falling asleep or during sleep?

Yes

No

Have you been told that you kick your legs in bed?

Yes

No

Are you a restless sleeper (do you toss and turn in bed)

Yes

No

Are you a sleep walker?

Yes

No

Are you a sleep talker

Yes

No

Have you ever had violent jerks at night causing injury to yourself or your bedpartner?

Yes

No

Do you recall your dreams

Every night

Sometimes

Never

When you wake up in the morning do you feel refreshed?

Yes

No

Do you take a nap during the day?

Yes

No

Do you feel better after a nap?

Yes

No

Is there anyone in the family who is known to be sleepy all the time

Yes

No

Is there anyone in the family who is known to be tired all the time

Yes

No

Is there anyone in the family who is known to be a heavy snorer

Yes

No

Driving

Yes

No

Visiting People

Yes

No

People visiting you

Yes

No

At the table

Yes

No

Talking to people

Yes

No

Watching TV

Yes

No

Having sex

Yes

No

Sitting and reading

0

1

2

3

Watching TV

0

1

2

3

Sitting, inactive in a public place ( e.g, a theatre or a meeting)

0

1

2

3

As a passenger in a car for an hour without a break

0

1

2

3

Lying down to rest in the afternoon when circumstances permit

0

1

2

3

Sitting and talking to someone

0

1

2

3

Sitting quietly after lunch without alcohol

0

1

2

3

In a car, while stopped for a few minutes in traffic

0

1

2

3

Cannot get to sleep within 30 minutes

Not during the past month (0)

Less than once a week (1)

Once or twice a week (2)

Three of more times a week (3)

Wake up in the middle of the night or early morning

Not during the past month (0)

Less than once a week (1)

Once or twice a week (2)

Three of more times a week (3)

Have to get up to use the bathroom

Not during the past month (0)

Less than once a week (1)

Once or twice a week (2)

Three of more times a week (3)

Cannot breathe comfortable

Not during the past month (0)

Less than once a week (1)

Once or twice a week (2)

Three of more times a week (3)

Cough or snore loudly

Not during the past month (0)

Less than once a week (1)

Once or twice a week (2)

Three of more times a week (3)

Feel too cold

Not during the past month (0)

Less than once a week (1)

Once or twice a week (2)

Three of more times a week (3)

Feel too hot

Not during the past month (0)

Less than once a week (1)

Once or twice a week (2)

Three of more times a week (3)

Have bad dreams

Not during the past month (0)

Less than once a week (1)

Once or twice a week (2)

Three of more times a week (3)

Have pain

Not during the past month (0)

Less than once a week (1)

Once or twice a week (2)

Three of more times a week (3)

Other reason(s), please describe, including how odten you have had trouble sleeping business of this reason(s)

Not during the past month (0)

Less than once a week (1)

Once or twice a week (2)

Three of more times a week (3)

During the past month, how often have you taken medicine (prescribed or "over the counter") to help you sleep?

Not during the past month (0)

Less than once a week (1)

Once or twice a week (2)

Three of more times a week (3)

During the past month, how often have you had trouble staying awake while driving, eating meals, or engaging in social activity?

Not during the past month (0)

Less than once a week (1)

Once or twice a week (2)

Three of more times a week (3)

During the past month, how much of a problem has it been for you to keep up enthusiasm to get things done?

Not during the past month (0)

Less than once a week (1)

Once or twice a week (2)

Three of more times a week (3)

During the past month, how would you rate your sleep quality overall?

Very good (0)

Fairly good (1)

Fairly bad (2)

Very bad (3)