1

UNIVERSITY OF MICHIGAN SLEEP DISORDERS CENTER

QUESTIONNAIRE

INSTRUCTIONS

The questions in this booklet will help us understand your sleep/wake problems. Please answer each

question as completely and as accurately as possible. Answers to these questions will be kept confiden-

tial. Some questions might be better answered by your spouse, bed-partner, parent, or roommate.

Please ask for help from such a person if appropriate. Do not spend too much time on any question.

Your first impression is generally the best.

The time period of all questions is THE PRESENT (which includes THE LAST 6 MONTHS) unless other-

wise specified.

A “WEEKDAY” is any day on which you normally work. For most people, it is Monday-Friday. Howev-

er, if you are engaged in shift work, or have an unusual schedule, then “DAYTIME” AND “NIGHTTIME” re-

fer to your own major waking and sleeping periods.

Many of the questions begin with “HOW OFTEN….”, and five choices are offered. These should be an-

swered by circling the appropriate number:

Please list your: NAME:____________________________________

UM 9-digit MRN#:____________________________

Birthdate: _________________________________

Today’s date: ______________________________

Now please turn the page—REMEMBER, the questions are on BOTH SIDES of the page.

Never or

almost never

1

Seldom

Not more than

once per month

2

Occasionally

1-3 times per

month

3

Often

More than 1-2

times per week

4

Always or

Almost always or

almost everyday

5

2

1. Do you feel that you have insomnia..………………………………………………………………………….

If yes, for how many years have you had insomnia?.................................................

2. Do you feel that you are excessively sleepy?....................................................................

If yes, for how many years have you been excessively sleepy? ……………………………..

3. What time do you usually go to bed:

On weekdays?............................................................................................................

On weekends?............................................................................................................

4. What time do you usually get up:

On weekdays?............................................................................................................

On weekends?............................................................................................................

5. How long does it usually take you to fall asleep after deciding to go to sleep?................

6. What is the total number of hours of sleep that you usually get at night? (Do not

include time that you spend awake in bed during the night)…………………………………..

7. How many times do you wake up during a typical night’s sleep?....................................

8. How many times do you get out of bed during a typical night’s sleep?...........................

9. How long does it usually take you to “get going” after you get out of bed?...................

10. How many naps do you take on purpose in a usual weekday?......................................

11. What is the total amount of sleep that you get during naps in a usual weekday?.......

Yes NO

_____ Years

Yes No

_____ Years

_____

_____

AM

PM

_____

_____

AM

PM

_____

_____

AM

PM

_____

_____

AM

PM

_____hr _____min

_____hr

_____min

_____

_____

_____hr _____min

_____

_____hr _____min

HOW OFTEN do you :

12. - have difficulty getting to sleep at night?.......................................................................... 1 2 3 4 5

13. - have restless legs (crawling or aching feelings and inability to keep your legs still)

When trying to get to sleep?......................................................................................... 1 2 3 4 5

14. - have leg cramps (Charlie horses) at night?....................................................................... 1 2 3 4 5

15. - paraesthesias (pins and needles feelings) in your hands, arms, legs, or feet at night?... 1 2 3 4 5

16. - have a poor night’s sleep?............................................................................................... 1 2 3 4 5

17. - have irregular sleep habits (more than 4 hours different from your usual bedtime

And wake-up time)?...................................................................................................... 1 2 3 4 5

1 = Never 2 = Seldom 3 = Occasionally 4 = Often 5 = Almost always

3

HOW OFTEN do you….

18. - work nights?...................................................................................................... 1 2 3 4 5

19. - have restless, disturbed sleep or disturb the sleep of your bed partner? ....... 1 2 3 4 5

20. - snore in any way?............................................................................................. 1 2 3 4 5

21. - snore loudly and disruptively?.......................................................................... 1 2 3 4 5

22. - hold your breath or stop breathing during sleep?............................................ 1 2 3 4 5

23. - walk in your sleep?............................................................................................ 1 2 3 4 5

24. - talk in your sleep?.............................................................................................. 1 2 3 4 5

25. - ”act-out” your dreams?...................................................................................... 1 2 3 4 5

26. - grind your teeth during sleep?........................................................................... 1 2 3 4 5

27. - have twitching or kicking of your legs during sleep?.......................................... 1 2 3 4 5

28. - have nightmares?................................................................................................ 1 2 3 4 5

29. - feel extremely alert and energetic during the whole day?................................. 1 2 3 4 5

30. - feel sleepy (struggling to stay awake) during the day?....................................... 1 2 3 4 5

31. - have a MAJOR PROBLEM with sleepiness in the daytime?................................. 1 2 3 4 5

32. - have a major problem with FATIGUE (tiredness, exhaustion, lethargy)

Even when you are NOT sleepy?.................................................................. 1 2 3 4 5

33. - have a major problem with your performance at school or at work

Because of sleepiness or fatigue?................................................................ 1 2 3 4 5

34. - have a major problem with driving because of sleepiness?............................... 1 2 3 4 5

35. - have vivid dream-like images or hallucinations even though you are still awake:

- when falling asleep?................................................................................... 1 2 3 4 5

- when awakening?....................................................................................... 1 2 3 4 5

36. - feel paralyzed (unable to move):

- when falling asleep?................................................................................... 1 2 3 4 5

- when awakening?....................................................................................... 1 2 3 4 5

37. - find that you have performed a complex act, such as driving a car to the

wrong destination, and not remembering how you did it?.......................... 1 2 3 4 5

1 = Never 2 = Seldom 3 = Occasionally 4 = Often 5 = Almost always

4

HOW OFTEN do you….

38. - find yourself doing things that make no sense, such as writing nonsense

or mixing chocolate with gravy?................................................................. 1 2 3 4 5

39. - get told that you were acting strangely without being aware of it at the time? 1 2 3 4 5

40. - have a feeling of “weak knees” when you laugh?............................................. 1 2 3 4 5

41. - have episodes of sudden muscular weakness (paralysis or inability to move)

when laughing, angry, or in other emotional or exciting situations?......... 1 2 3 4 5

42. - feel that you are under a great deal of stress?.................................................. 1 2 3 4 5

43. - have something to eat during the night?.......................................................... 1 2 3 4 5

44. - drink something alcoholic within 2 hours of trying to go to sleep?.................. 1 2 3 4 5

45. - drink something alcoholic during the night?.................................................... 1 2 3 4 5

46. - drink something alcoholic to help you sleep?.................................................. 1 2 3 4 5

47. In the past 6 months, how often have you FALLEN ASLEEP without intending to while:

a. reading a book in bed……………………………………………………………………….. 1 2 3 4 5

b. reading a book (not in bed)………………………………………………………………. 1 2 3 4 5

c. listening to the radio or stereo…………………………………………………………. 1 2 3 4 5

d. watching television………………………………………………………………………….. 1 2 3 4 5

e. attending a movie, play, lecture……………………………………………………….. 1 2 3 4 5

f. traveling (car, bus, train)…………………………………………………………………... 1 2 3 4 5

g. talking in a group (e.g. with guests at home)……………………………………. 1 2 3 4 5

h. in conversation with another person……………………………………………….. 1 2 3 4 5

i. on the telephone………………………………………………………………………………. 1 2 3 4 5

J. eating food……………………………………………………………………………………….. 1 2 3 4 5

k. having intercourse……………………………………………………………………………. 1 2 3 4 5

48. In the past 6 months, how often have you felt very sleepy or STRUGGLED TO STAY AWAKE while:

a. reading a book in bed……………………………………………………………………….. 1 2 3 4 5

b. reading a book (not in bed)………………………………………………………………. 1 2 3 4 5

c. listening to the radio or stereo…………………………………………………………. 1 2 3 4 5

d. watching television………………………………………………………………………….. 1 2 3 4 5

1 = Never 2 = Seldom 3 = Occasionally 4 = Often 5 = Almost always

5

e. attending a movie, play, lecture…………………………………………………………. 1 2 3 4 5

f. traveling (car, bus, train)……………………………………………………………………. 1 2 3 4 5

g. talking in a group (e.g. with guests at home)…………………………………….. 1 2 3 4 5

h. in conversation with another person…………………………………………………. 1 2 3 4 5

i. on the telephone……………………………………………………………………………….. 1 2 3 4 5

j. eating food…………………………………………………………………………………………. 1 2 3 4 5

k. having intercourse…………………………………………………………………………….. 1 2 3 4 5

49. Do you drive a car?.............................................................................................. Yes No

If not, skip to question 53

50. About how many miles do you drive per year?................................................... ________miles

51. In the past 6 MONTHS, as a DRIVER:

- how many times have you been involved in automobile accidents?...... ________

- how many times have your accidents been caused by sleepiness?........ ________

- how many times have you had near accidents (driving onto the

shoulder or off the road, etc.) because of sleepiness?........................... ________

52. In your LIFETIME as a DRIVER:

- how many times have you been involved in automobile accidents?...... ________

- how many times have your accidents been caused by sleepiness?........ ________

- how many times have you had near accidents (driving onto the

shoulder or off the road etc.) because of sleepiness?........................... ________

53. Do you drink alcohol?........................................................................................ Yes No

If no, skip to question 57

54. How many bottles (cans) of beer do you have

- during a usual 24 hour weekday?.......................................................... ________

- during a usual 24 hour weekend day?................................................... ________

6

55. How many glasses of wine do you have

- during a usual 24 hour weekday?........................................................... ______

- during a usual 24 hour weekend day?.................................................... ______

56. How many shots of liquor do you have

- during a usual 24 hour weekday?........................................................... ______

- during a usual 24 hour weekend day?................................................... ______

57. How many packs of cigarettes do you smoke per day?..................................... ______

- for how many years?............................................................................. ______

58. How many cups of caffeinated coffee or tea or cola do you drink per day?.... ______

59. Weight: __________ pounds

60. Height: _____ ft. ______ in.

61. Have you had any sleep testing at another hospital or sleep center?............. Yes No

If so, please list the name(s), address(es), and date(s):

______________________________________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________

62. Please list any prescription medications that you take to help you sleep:

_____________________________ _____________________________

_____________________________ _____________________________

63. Please list any non-prescription medications that you take to help you sleep:

_____________________________ _____________________________

_____________________________ _____________________________

64. Please list any other prescription medications that you take:

_____________________________ _____________________________

_____________________________ _____________________________

_____________________________ _____________________________

65. Please list any other non-prescription medications that you take:

_____________________________ _____________________________

_____________________________ _____________________________

_____________________________ _____________________________

7

66. Is there anything else that affects your sleep/wake patterns?

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

8

NAME __________________________________ MRN#__________________________

UNIVERSITY OF MICHIGAN SLEEPINESS IMPACT ASSESSMENT

Sleep Lab Clinical Version, revised 3/19/1997

General Instructions:

The following questions ask about the effect that sleepiness might have on your daily life. Following each

item please circle the response that best characterizes how you have felt on average during the past 30 days.

Please answer each question as best you can, whether or not you consider yourself to be a sleepy person.

There are no “right” or “wrong” answers to any of these questions. Should you have any questions about

this questionnaire, please ask the person who gave it to you.

A. THIS FIRST SET OF QUESTIONS ASK ABOUT HOW SLEEPINESS HAS AFFECTED YOUR WELL-BEING DURING

THE PAST 30 DAYS. PLEASE CIRCLE ONE RESPONSE FOR EACH QUESTION.

1. Sleepiness interferes with my ability to do my job.

2. Sleepiness interferes with my ability to work around the house.

3. Sleepiness interferes with my ability to do my class work.

4. I am too sleepy to enjoy myself during my free time.

5. Sleepiness limits my social life.

1

Never

2

Seldom

3

Occasionally

4

Often

5

Almost Always

6

I have no job

1

Never

2

Seldom

3

Occasionally

4

Often

5

Almost Always

6

I do no work

around the house

1

Never

2

Seldom

3

Occasionally

4

Often

5

Almost Always

6

I take no classes

1

Never

2

Seldom

3

Occasionally

4

Often

5

Almost Always

1

Never

2

Seldom

3

Occasionally

4

Often

5

Almost Always

9

6. Sleepiness limits my ability to exercise.

7. I have to limit my driving due to sleepiness.

8. I am in danger of having an accident while driving because of sleepiness.

9. I am unable to accomplish as much as I would like because of sleepiness.

10. My ability to read is affected by sleepiness.

11. I am afraid I will fall asleep in front of friends or people I work with.

12. I have difficulty staying awake while I watch TV.

PLEASE CIRCLE ONE AND ONLY ONE RESPONSE TO EACH QUESTION

1

Never

2

Seldom

3

Occasionally

4

Often

5

Almost always

6

Not applicable

1

Never

2

Seldom

3

Occasionally

4

Often

5

Almost always

6

I do not drive

1

Never

2

Seldom

3

Occasionally

4

Often

5

Almost always

1

Never

2

Seldom

3

Occasionally

4

Often

5

Almost always

6

I do not drive

1

Never

2

Seldom

3

Occasionally

4

Often

5

Almost always

1

Never

2

Seldom

3

Occasionally

4

Often

5

Almost always

6

I do not read

1

Never

2

Seldom

3

Occasionally

4

Often

5

Almost always

6

I watch no TV

10

13. I fall asleep when I am in a quiet, comfortable place even when I don’t want to sleep;

14. I have difficulty following conversations because of sleepiness.

15. Sleepiness has a bad effect on my mood.

16. Sleepiness causes me to have little patience.

17. Sleepiness makes it difficult for me to participate in evening activities.

18. I treat family and friends worse because of my level of sleepiness.

19. My level of sleepiness embarrasses me.

PLEASE CIRCLE ONE AND ONLY ONE RESPONSE TO EACH QUESTION

1

Never

2

Seldom

3

Occasionally

4

Often

5

Almost always

1

Never

2

Seldom

3

Occasionally

4

Often

5

Almost always

1

Never

2

Seldom

3

Occasionally

4

Often

5

Almost always

1

Never

2

Seldom

3

Occasionally

4

Often

5

Almost always

1

Never

2

Seldom

3

Occasionally

4

Often

5

Almost always

1

Never

2

Seldom

3

Occasionally

4

Often

5

Almost always

1

Never

2

Seldom

3

Occasionally

4

Often

5

Almost always

11

20. Sleepiness is a problem for me.

21. Overall, I am less happy because of sleepiness.

22. Fatigue is a problem for me.

23. Tiredness is a problem for me.

24. Lack of energy is a problem for me.

25. I have difficulty paying attention.

26. I have difficulty concentrating.

PLEASE CIRCLE ONE AND ONLY ONE RESPONSE TO EACH QUESTION

1

Never

2

Seldom

3

Occasionally

4

Often

5

Almost always

1

Never

2

Seldom

3

Occasionally

4

Often

5

Almost always

1

Never

2

Seldom

3

Occasionally

4

Often

5

Almost always

1

Never

2

Seldom

3

Occasionally

4

Often

5

Almost always

1

Never

2

Seldom

3

Occasionally

4

Often

5

Almost always

1

Never

2

Seldom

3

Occasionally

4

Often

5

Almost always

1

Never

2

Seldom

3

Occasionally

4

Often

5

Almost always

12

27. I have difficulty with my memory.

28. I feel depressed.

29. I feel stressed.

30. I feel hopeful.

B. EACH OF THE NEXT QUESTIONS IS DESIGNED TO FIND OUT WHICH WORD BEST DESCRIBES WHAT

BOTHERS YOU MOST. PLEASE FILL IN THE BLANK AFTER EACH QUESTION WITH ONE OF THE FOLLOW

ING ANSWERS:

Sleepiness(1) Fatigue(2) Lack of energy(3) Tiredness(4)

1. Which most affects your ability to accomplish what you want?

______________________________

2. Which is the worst problem for you?

______________________________

3. If you could be cured completely of only one of these problems, which would you choose?

_______________________________

1

Never

2

Seldom

3

Occasionally

4

Often

5

Almost always

1

Never

2

Seldom

3

Occasionally

4

Often

5

Almost always

1

Never

2

Seldom

3

Occasionally

4

Often

5

Almost always

1

Never

2

Seldom

3

Occasionally

4

Often

5

Almost always

13

C. PLEASE WRITE IN YOUR ANSWERS TO THE NEXT TWO QUESTIONS:

1. What is the single most significant limitation you experience because of sleepiness?

2. Please list three ways that sleepiness affects you other then those discussed above.

1.__________________________________________________

2. __________________________________________________

3. __________________________________________________

D. ADDITIONAL INFORMATION

1. Where are you completing this questionnaire? (check one and if “other” please describe)

______ Sleep Laboratory

______ Sleep or Neurology Clinic

______ Other Location ______________________________

2. Sex: ______ Male

______ Female

3. Your Occupation: ___________________________________________

______ Full Time

______ Part Time

4. Do you drive a motor vehicle?

______ No ______ Yes, I drive: _____Daily

_____ Several days a week

_____ Two or fewer days a week

14

MEDICAL OUTCOME

INSTRUCTIONS: Answer every question by checking the appropriate box, 1, 2, 3, etc. If you are unsure

about how to answer a question, please give the best answer you can. CHECK ONE BOX

1. In general, would you say your health is:

1 Excellent 2Very good 3Good 4 Fair 5 Poor

2. Compared to one year ago, how would you rate your health in general now?

1 Much better now than one year ago 4 Somewhat worse now than one year ago

2 Somewhat better now than one year ago 5 Much worse now than one year ago

3 About the same

3. The following questions are about activities you might do during a typical day. During the past 8 weeks

has your health limited you in these activities? If so how much? Check one box on each line.

Yes, Limited

A lot

Yes, Limited A little

No, not limited at all

a. Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports

1 2 3

b. Moderate activities such as moving a table, pushing a vacuum cleaner, bowling, or playing golf

1 2 3

c. Lifting or carrying groceries 1 2 3

d. Climbing several flights of stairs 1 2 3

E. Climbing one flight of stairs 1

2 3

f. Bending, kneeling, or stooping 1 2 3

g. Walking more than a mile 1 2 3

h. Walking several blocks 1 2 3

i. Walking one block 1 2 3

J. Bathing and dressing yourself 1 2 3

15

4. During the past 8 weeks, have you had any of the following problems with your work or other regular daily activities as a result of your physical health? (Please answer yes or no by checking the appropriate box).

5. During the past 8 weeks, have you had any of the following problems with your work or other regular daily activities as a result of any emotional problems (such as feeling depressed or anxious)? (Please an-swer yes or no by checking the appropriate box).

6. During the past 8 weeks, to what extent has your physical health or emotional problems interfered with your normal social activities with family, friends, neighbors, or groups? (check one box)

7. How much bodily pain have you had during the past 8 weeks? (check one box)

8. During the past 8 weeks, how much did pain interfere with your normal work (including work both out-side the home and housework)? (check one box)

9. These questions are about how you feel and how things have been with you during the past 8 weeks. For each question, please indicate the one answer that comes closest to the way you have been feeling. (check one box on each line).

a. Cut down on the amount of time you spent on work or other activities

o No 1 Yes

b. Accomplished less than you would like 1 Yes o No

c. Were limited in the kind of work or other activities 1 Yes o No

d. Had difficulty performing work or other activities 1 Yes o No

a. Cut down on the amount of time spent on work or other activities

1 Yes o No

b. Accomplished less than you would like 1 Yes o No

c. Didn’t do work or other activities as carefully as usual 1 Yes o No

1 Not at all 2 Slightly 3 Moderately 4 Quite a bit 5 Extremely

1 None 2 Very Mild 3 Mild 4 Moderate 5 Severe 6 Very Severe

1 Not at all 2 Slightly 3 Moderately 4 Quite a bit 5 Extremely

16

How much of the time during the

past 8 weeks

All of the

Time

Most of

the Time

A good

bit of

the Time

Some

of the

Time

A Little

of the

Time

None

of the

Time

a. did you feel full of pep? 1 2 3 4 5 6

b. have you been a very nervous person? 1 2 3 4 5 6

c. have you felt so down in the dumps

nothing could cheer you up ?

1

2

3

4

5

6

d. have you felt calm and peaceful? 1 2 3 4 5 6

e. did you have a lot of energy? 1 2 3 4 5 6

f. have you felt downhearted and blue? 1 2 3 4 5 6

g. did you feel worn out? 1 2 3 4 5 6

h. have you been a happy person? 1 2 3 4 5 6

i. did you feel tired? 1 2 3 4 5 6

J. has your health limited your social activi

ties ( like visiting with friends or close

relatives)?

1

2

3

4

5

6

Definitely True

Mostly True

Not Sure

Mostly False

Definitely False

a. I seem to get sick a little easier than other

people.

1

2

3

4

5

b. I am as healthy as anybody I know.

1

2

3

4

5

c. I expect my health to get worse.

1

2

3

4

5

d. My health is excellent.

1

2

3

4

5

10. Please choose the answer that best describes how true or false each of the following statements is

for you. (Check one box on each line).

SUBJECT’S INITIALS: _____________