Pittsburgh Sleep Quality Index (PSQI)

       ID:         DATE:           TIME (24hr): 


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 (24 hOUR FORMAT): HH:MM

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

NUMBER OF MINUTES: HH:MM

3. During the past month, what time have you usually gotten up in the morning?

GETTING UP TIME (24 HOUR FORMAT): HH : MM

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 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
0 1 2 3 4 5 6 7 8 9 10
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):

Very Good Fairly Good Fairly Bad Very Bad
0 1 2 3 4 5 6 7 8 9 10
6. During the past month, how would you rate your sleep quality overall? (Fill in one answer.)

Not during the last month Less than once a week Once or twice a week Three or more times a week
0 1 2 3 4 5 6 7 8 9 10
7. During the past month, how often have you taken medicine to help you sleep (prescribed or “over the counter”)? (Fill in one answer.)
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.)

No problem at all Only a very slight problem Somewhat of a problem A very big problem
0 1 2 3 4 5 6 7 8 9 10
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 bed partner or roommate Partner/roommate in other room Partner in same room, but not in same bed Partner in same bed
0 1 2 3 4 5 6 7 8 9 10
10. Do you have a bed partner or roommate? (Fill in one answer.)

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 last month Less than once a week Once or twice a week Three or more times a week
0 1 2 3 4 5 6 7 8 9 10
Loud snoring
Long pauses between breaths while asleep
Legs twitching or jerking while you sleep
Other restlessness while you sleep...



TEXT FOR YOUR RECORDS

APW  maximum score = 80

0    -  19      normal
20  -  39      mild
40  -  59      moderate
60  -  69      severe
70  -  80      extreme

DATA FILE

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Last update: 10/13/2015