• Over the past 4 weeks, what time did you usually turn the lights off to go to sleep? (Hours, minutes) |
• Over the past 4 weeks, what time did you usually get out of bed? (Hours, minutes) |
• Over the past 4 weeks, how many hours do you think you actually slept each day? (Hours) |
• During the past 4 weeks, how often did you wake up in the middle of the night or early morning? (“Never”/”Less than once per week”/”Once or twice a week”/”Three of more times a week”) |
• During the past month, have you snored, or ever been told that you were snoring? (“Yes”/”No”) |
• During the past month, have you snored loudly, or ever been told that you were snoring loudly? (“Yes”/”No”) |
• During the last month, have you had, or ever been told that your breathing stops or you struggle for breath? (“Yes”/”No”) |
• During the last month, have you had, or ever been told that you were snorting or gasping? (“Yes”/”No”) |
• On a scale of 0 to 10, where 0 is “Does not interfere” and 10 is “Completely interferes”, select the one number that describes how, during the past 24 hours, pain has interfered with your sleep. |
• Over the past 4 weeks, how would you rate your sleep quality overall? (“Very good”/”Fairly good”/”Fairly bad”/”Very bad”) |
• During the past 4 weeks, how often could you not get to sleep within 30 minutes? (“Never”/”Less than once per week”/”Once or twice a week”/”Three of more times a week”) |
• In your life, have you ever had any experience that was so frightening, horrible, or upsetting that, in the past 30 days you had more trouble than usual falling asleep or staying asleep? |
• Much of the time in the past week, your sleep was restless. (“Yes”/”No”) |
• How often during the past 4 weeks did you get enough sleep to feel rested upon waking up? (“Never”/”Rarely”/”Sometimes”/”Often”/”Very often”) |