Sleep Scale Sleep Scale Your Name Date of Birth Gender ---FemaleMale Surgery Doctor Date PLEASE ANSWER THE FOLLOWING 12 QUESTIONS OF THIS HEALTH SURVEY COMPLETELY, HONESTLY AND WITHOUT INTERRUPTIONS. 1. How long did it usually take for you to fall asleep during the past 4 weeks? ---1 0-15 minutes2 16-30 minutes3 31-45 minutes4 46-60 minutes5 Over 60 minutes 2. On the average, how many hours did you sleep each night during the past 4 weeks? How often during the past 4 weeks did you… 3. Feel that your sleep was not quiet (moving restlessly, feeling tense, speaking, etc., while sleeping)? ---1 All of the time2 Most of the time3 A good bit of the time4 Some of the time5 A little bit of the time6 None of the time 4. Get enough sleep to feel rested upon waking in the morning? ---1 All of the time2 Most of the time3 A good bit of the time4 Some of the time5 A little bit of the time6 None of the time 5. Awaken short of breath or with a headache? ---1 All of the time2 Most of the time3 A good bit of the time4 Some of the time5 A little bit of the time6 None of the time 6. Feel drowsy or sleepy during the day? ---1 All of the time2 Most of the time3 A good bit of the time4 Some of the time5 A little bit of the time6 None of the time 7. Have trouble falling asleep? ---1 All of the time2 Most of the time3 A good bit of the time4 Some of the time5 A little bit of the time6 None of the time 8. Awaken during your sleep time and have trouble falling asleep again? ---1 All of the time2 Most of the time3 A good bit of the time4 Some of the time5 A little bit of the time6 None of the time 9. Have trouble staying awake during the day? ---1 All of the time2 Most of the time3 A good bit of the time4 Some of the time5 A little bit of the time6 None of the time 10. Snore during your sleep? ---1 All of the time2 Most of the time3 A good bit of the time4 Some of the time5 A little bit of the time6 None of the time 11. Take naps (5 minutes or longer) during the day? ---1 All of the time2 Most of the time3 A good bit of the time4 Some of the time5 A little bit of the time6 None of the time 12. Get the amount of sleep you needed? ---1 All of the time2 Most of the time3 A good bit of the time4 Some of the time5 A little bit of the time6 None of the time THANK YOU FOR COMPLETING THIS QUESTIONNAIRE STAFF USE ONLY Participants NHS Number: Researchers Name: NHS Site Number:
