The following questions are about your sleep situation in the past month. Please choose the answer that best matches your actual situation in the past month. Please answer the following questions:
1. In the past month, what time do you usually go to bed at night? ( ) o'clock
2. In the past month, how many minutes does it usually take you to fall asleep after going to bed? ( ) minutes
3. In the past month, what time do you usually get up in the morning? ( ) o'clock
4. In the past month, how many hours of actual sleep do you usually get each night? (This is not the same as the number of hours you spend in bed) ( ) hours
5a. In the past month, have you had trouble sleeping (unable to fall asleep within 30 minutes)?
5b. In the past month, have you had trouble waking up in the middle of the night or waking up too early?
5c. In the past month, have you had to go to the bathroom at night?
5d. In the past month, have you had trouble breathing at night?
5e. In the past month, have you had a cough or loud snoring?
5f. In the past month, have you felt cold?
5g. In the past month, have you felt hot?
5h. In the past month, have you had nightmares?
5i. In the past month, have you had pain or discomfort?
5j. In the past month, have there been other things affecting your sleep?
6. In the past month, how would you rate your overall sleep quality?
7. In the past month, how often have you used medication to help you sleep?
8. In the past month, have you often felt sleepy?
9. In the past month, have you lacked energy to do things?
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