Form 0920- Pittsburgh Sleep Quality Index

Attachment D12

Pittsburgh Sleep Quality Index

Form Approved

OMB No. 0920-xxxx

Exp. Date xx/xx/20xx

Pittsburgh Sleep Quality Index

III. 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.

1. During the past month, when have you usually gone to bed?

___ ___: ___ ___ AM

PM

2. During the past month, how long, in minutes, has it usually taken you to fall asleep?

___ ___ minutes

3. During the past month, when have you usually gotten up?

___ ___: ___ ___ AM

PM

4. During the past month, how many hours of actual sleep did you get per night? (This may be different than the number of hours you spend in bed.)

___ ___

5. For the remaining questions, please check the one best response. Please answer ALL questions.

During the PAST MONTH, how often have you had trouble sleeping because you . . .
		Not during the past month (1)	Less than once a week (2)	Once or twice a week (3)	Three or more times a week (4)
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 and use the bathroom	□	□	□	□
D	Cannot breathe comfortably	□	□	□	□
E	Cough or snore loudly	□	□	□	□
F	Feel too cold	□	□	□	□
G	Feel too hot	□	□	□	□
H	Have bad dreams	□	□	□	□
I	Have pain	□	□	□	□
J	Other reasons Please describe: ________ ______________________	□	□	□	□

Public reporting burden of this collection of information is estimated to average 2 minute 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 CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (XXXX).

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

□ (1) Very good

□ (2) Fairly good

□ (3) Fairly bad

□ (4) Very bad

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

□ (1) Not during the past month

□ (2) Less than once a week

□ (3) Once or twice a week

□ (4) 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?

□ (1) Not during the past month

□ (2) Less than once a week

□ (3) Once or twice a week

□ (4) 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?

□ (1) No problem at all

□ (2) Only a very slight problem

□ (3) Somewhat of a problem

□ (4) A very big problem

10. Do you have a bed partner or share a room?

□ (1) No bed partner or do not share a room

□ (2) Partner/mate in other room

□ (3) Partner in same room, but not in same bed

□ (4) Partner in same bed