The questionnaire assesses sleep quality over the past month based on 7 indicators of sleep quality. Please answer all questions to receive your results.
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Pittsburgh Sleep Quality Index (PSQI)
The questionnaire assesses sleep quality over the past month based on 7 indicators of sleep quality. Please answer all questions to receive your results.
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| First Name | Last Name | ||
| Date | Date of Birth |
Instructions: The following questions refer to your sleep during the past MONTH. Please answer all questions.
1. During the past month, when have you usually gone to bed at night?
2. How long (in minutes) has it usually taken you to fall asleep each night?
3. During the past month, when have you usually gotten up in the morning?
4. How many hours of actual sleep did you get at night during the past month?
(This may be different from the number of hours you spent in bed)
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 |
|
| (a) could not get to sleep within 30 minutes | ||||
| (b) woke up in the middle of the night or early morning | ||||
| (c) had to get up to use the bathroom | ||||
| (d) could not breathe comfortably | ||||
| (e) coughed or snored loudly | ||||
| (f) felt too cold | ||||
| (g) felt too hot | ||||
| (h) had bad dreams | ||||
| (i) had pain | ||||
|
(j) Other reason(s), please describe: How often have you had trouble sleeping because of this?
|
6. During the past month, how would you rate your overall sleep quality?
7. During the past month, how often have you taken medicine (prescribed or “over the counter”) to help you sleep?
| Not during the past month |
Less than once a week |
Once or twice a week |
Three or more times a week |
8. During the past month, how often have you had trouble staying awake while driving, eating meals, or engaging in social activity?
| Not during the past month |
Less than once a week |
Once or twice a week |
Three or more times a week |
9. During the past month, how much of a problem has it been for you to keep up enough enthusiasm to get things done?
10. Do you have a bed partner or roommate?
11. If you have a bed partner or roommate, ask them how often in the past month you have had...
| Not during the past month |
Less than once a week |
Once or twice a week |
Three or more times a week |
|
| (a) Loud snoring | ||||
| (b) Long pauses in breathing while asleep | ||||
| (c) Leg or arm jerks during sleep | ||||
| (d) Episodes of confusion or disorientation during sleep | ||||
| (e) Other restlessness during sleep: describe |
Frequency:
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