1. During the past month, what time have you usually gone to bed at night?
2. During the past month, how long (in minutes) has it usually taken you to fall asleep each night?
3. During the past month, what time have you usually gotten up in the morning?
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.)
5. Cannot get to sleep within 30 minutes
6. Wake up in the middle of the night or early morning
7. Have to get up to use the bathroom
8. Cannot breathe comfortably
9. Cough or snore loudly
10. Feel too cold
11. Feel too hot
12. Had bad dreams
13. Have pain
14. Other restlessness while you sleep; please describe
15. During the past month, how would you rate your sleep quality overall?
16. During the past month, how often have you taken medicine to help you sleep (prescribed or over the counter)?
17. During the past month, how often have you had trouble staying awake while driving, eating meals, or engaging in social activity?
18. During the past month, how much of a problem has it been for you to keep up enough enthusiasm to get things done?