WRIISC Health Questionnaire             V20151016
 Section 12: Sleep

    DATE:           TIME (24hr):      Patient Code:  

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.


         BED TIME (24 HOUR FORMAT):


         NUMBER OF MINUTES:


         GETTING UP TIME (24 HOUR FORMAT):

       (This may be different than the number of hours you spent in bed.)

         HOUR OF SLEEP PER NIGHT:




  For each of the remaining questions, fill in one best response. Please answer all questions.

5. During the past month, how often have you had trouble sleeping because you...

NOT DURING THE PAST MONTH

LESS THAN ONCE A WEEK

ONCE OR TWICE A WEEK

THREE OR MORE TIMES A WEEK

  1.  Cannot get to sleep within 30 minutes

  
  
  
  
  2.  Wake up in the middle of the night or early morning
  

  

  

  

  3.  Have to get up to use the bathroom
  

  

  

  

  4.  Cannot breathe comfortably
  

  

  

  

  5.  Cough or snore loudly

  
  
  
  
  6.  Feel too cold

  

  

  

  

  7.  Feel too hot

  

  

  

  

  8.  Had bad dreams

  

  

  

  

  9.  Have pain

  

  

  

  

 10. Other reason(s)...
         Please describe other reason(s):
  

  

  

  



6. During the past month, how would you rate your sleep quality overall? (Fill in one answer.)

                  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”)? (Fill in one answer.)

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? (Fill in one answer.)

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? (Fill in one answer.)

  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 roommate? (Fill in one answer.)

   No bed partner or roommate    Partner/roommate in other room

   Partner in same room, but not same bed   Partner in same bed



  If you have a roommate or bed partner, ask him/her how often in the past month you have had... (Fill in one answer for each item.)

NOT DURING THE PAST MONTH

LESS THAN ONCE A WEEK

ONCE OR TWICE A WEEK

THREE OR MORE TIMES A WEEK

  Loud snoring

  

  

  

  

  Long pauses between breaths while asleep

  

  

  

  

  Legs twitching or jerking while you sleep

  

  

  

  

  Episodes of disorientation or confusion during sleep

  

  

  

  

  Other restlessness while you sleep...

  

  

  

  

Please describe:

    

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          Last update:  11/27/2019