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Pittsburgh Sleep Quality Index
INSTRUCTIONS:
The following questions relate to your usual sleep habits during the past month
only
. Your answers should indicate the most accurate reply for the
majority
of days and nights in the past month.
Please answer all questions.
1. During the past month, what time have you usually gone to bed at night?
Bed Time
2. During the past month, how long (in minutes) has it usually taken you to fall asleep each night?
Number of Minutes
3. During the past month, what time have you usually gotten up in the morning?
Getting up Time
4. During the past month, how many hours of
actual sleep
did you get at night? (This may be different than the number of hours you spend in bed.)
Hours of Sleep Per Night
For each of the r
emaining questions, check the one best response. Please answer
all
questions.
5. During the past month, how often have you had trouble sleeping because you...
5. During the past month, how often have you had trouble sleeping because you...
Frequency
Not during the past month
Less than once a week
Once or twice a week
Three or more times a week
a) Cannot get to sleep within 30 minutes
b) Wake up in the middle of the night or early morning
c) Have to get up to use the bathroom
d) Cannot breathe comfortably
e) Cough or snore loudly
f) Feel too cold
g) Feel too hot
h) Had bad dreams
i) Have pain
j) Other reason(s), please describe
6. During the past month, how would you rate your sleep quality overall?
Very good
Fairly good
Fairly bad
Very bad
7. During the past month, how often have you taken medicine to help you sleep (prescribed or "over the counter")?
Not during the past month
Less than once a week
Once or twice a week
Three or more times a week
8. 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
Less than once a week
Once or twice a week
Three or more times a week
9. During the past month, how much of a problem has it been for you to keep up enough enthusiasm to get things done?
No problem at all
Only a very slight problem
Somewhat of a problem
A very big problem
10. Do you have a bed partner or room mate?
No bed partner or room mate
Partner/room mate in other room
Partner in same room, but not same bed
Partner in same bed
If you have a room mate or bed partner, ask him/her how often in the past month you have had...
If you have a room mate or bed partner, ask him/her how often in the past month you have had...
Frequency
Not during the past month
Less than once a week
Once or twice a week
Three or more times a week
a) Loud snoring
b) Long pauses between breaths while asleep
c) Legs twitching or jerking while you sleep
d) Episodes of disorientation or confusion during sleep
Other restlessness while you sleep; please describe
11. University status:
Faculty/staff
Student
Omaha community member
12. University Classification (if student):
Freshman
Sophomore
Junior
Senior
Graduate
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