1. When do you usually go to bed at night during the week?
2. When do you usually go to bed at night during the weekend?
3. How long (in minutes) does it usually take you to fall asleep at night during the week?
4. How long (in minutes) does it usually take you to fall asleep at night during the weekend?
5. When do you usually wake up in the morning during the week?
6. When do you usually wake up in the morning during the weekend?
7. How many hours of actual sleep at night do you get during the week? (per night)
8. How many hours of actual sleep at night do you get during the weekend? (per night)
9. During the past month, how often have you had trouble sleeping because you could not get to sleep within thirty minutes?
a. Not at all during the past month
b. Less than once a week
c. Once or twice a week
d. Three or more times a week
10. During the past month, how often have you had trouble sleeping because you woke up in the middle of the night or early in the morning?
a. Not at all during the past month
b. Less than once a week
c. Once or twice a week
d. Three or more times a week
11. During the past month, how often have you had trouble sleeping because you had to get up to go to the bathroom?
a. Not at all during the past month
b. Less than once a week
c. Once or twice a week
d. Three or more times a week
12. During the past month, how often have you had trouble sleeping because you cough or snore loudly?
a. Not at all during the past month
b. Less than once a week
c. Once or twice a week
d. Three or more times a week
13. During the past month, how often have you had trouble sleeping because you were too cold?
a. Not at all during the past month
b. Less than once a week
c. Once or twice a week
d. Three or more times a week
14. During the past month, how often have you had trouble sleeping because you were too hot?
a. Not at all during the past month
b. Less than once a week
c. Once or twice a week
d. Three or more times a week
15. During the past month, how often have you had trouble sleeping because you had bad dreams?
a. Not at all during the past month
b. Less than once a week
c. Once or twice a week
d. Three or more times a week
16. During the past month, how often have you had trouble sleeping because you had pain?
a. Not at all during the past month
b. Less than once a week
c. Once or twice a week
d. Three or more times a week
17. Have you experienced other sleep difficulties?
a. If yes, skip to question 18
b. If no, skip to question 19
18. How often have you experienced these other sleep difficulties?
a. Not at all during the past month
b. Less than once a week
c. Once or twice a week
d. Three or more times a week
19. During the past month, how would you rate your sleep quality overall?
a. Very good
b. Fairly good
c. Fairly bad
d. Very bad
20. During the past month, how often have you taken medication (prescribed or over-the-counter) to help you sleep?
a. Not at all during the past month
b. Less than once a week
c. Once or twice a week
d. Three or more times a week
21. During the past month, how often have you had trouble staying awake while driving, eating meals or engaging in other social activities?
a. Not at all during the past month
b. Less than once a week
c. Once or twice a week
d. Three or more times a week
22. During the past month, how much of a problem has it been for you to keep up enough enthusiasm to get things done?
a. No problem at all
b. Slight problem
c. Somewhat of a problem
d. Big problem
For each of the following behaviors circle the number of days per week (from 0-7) that you engage in the activity or have that experience. Base your answers on what you would consider an average week for yourself. Indicate the number of days or nights in an average week you:
23. Take a nap: 0 1 2 3 4 5 6 7
24. Got to bed hungry: 0 1 2 3 4 5 6 7
25. Go to bed thirsty: 0 1 2 3 4 5 6 7
26. Smoke one or more packs of cigarettes:
0 1 2 3 4 5 6 7
27. Use sleeping medications (prescribed or over-the-counter):
0 1 2 3 4 5 6 7
28. Drink beverages containing caffeine within four hours of bedtime:
0 1 2 3 4 5 6 7
29. Drink more than three ounces of alcohol (3 mixed drinks, 3 beers, 3 glasses of wine) within four hours of bedtime:
0 1 2 3 4 5 6 7
30. Worry as you prepare for bed about your ability to sleep at night:
0 1 2 3 4 5 6 7
31. Worry during the day about your ability to sleep at night:
0 1 2 3 4 5 6 7
32. Use alcohol to facilitate sleep:
0 1 2 3 4 5 6 7
33. Exercise strenuously within 2 hours of bedtime:
0 1 2 3 4 5 6 7
34. Have your sleep disturbed by light:
0 1 2 3 4 5 6 7
35. Have your sleep disturbed by noise:
0 1 2 3 4 5 6 7
36. Have your sleep disturbed by your bed partner. Choose 0 if you have no bed partner:
0 1 2 3 4 5 6 7
37. Sleep approximately the same amount of time each night:
0 1 2 3 4 5 6 7
38. Set aside time to relax before bedtime:
0 1 2 3 4 5 6 7
39. Have a comfortable nighttime temperature in your bed or bedroom:
0 1 2 3 4 5 6 7
40. Exercise in the afternoon or early evening:
0 1 2 3 4 5 6 7
After you’ve answered the above questions, type a brief synopsis of your own sleep habits below. USING INFORMATION FROM THE TEXT and LESSON choose five of the questions above and indicate why they are included as being of interest in this study. Conclude by discussing ways you could improve your sleep habits. In terms of length, you could successfully do this in one or two typed, double spaced pages using 12 point’s font Times New Roman or Arial. (Remember you are typing the response below, continuing on to another page.)
