Tinnitus and hyperacusis therapy specialist unit

Insomnia

For each question, please tick the number that best describes your answer.

Please rate the CURRENT (i.e. LAST 2 WEEKS) SEVERITY of your sleep problem(s).

Name of the patient:

Your Email Address:

Please type the email address that this form needs to be sent to. This is often the email address of your clinician who asked you to complete this form.</small ></label >

For each question please select one number based on how you are feeling now.

Insomnia Problem	Mild	Moderate	Severe	Very Severe
1. Difficulty falling asleep	1	2	3	4
2. Difficulty staying asleep	1	2	3	4
3. Problems waking up too early	1	2	3	4

4. How SATISFIED/DISSATISFIED are you with your CURRENT sleep pattern?
Very Satisfied	Satisfied	Moderately Satisfied	Dissatisfied	Very Dissatisfied
0	1	2	3	4

5. How NOTICEABLE to others do you think your sleep problem is in terms of impairing the quality of your life?
Not at all Noticeable	A Little	Somewhat	Much	Very Much Noticeable
0	1	2	3	4

6. How WORRIED/DISTRESSED are you about your current sleep problem?
Not at all Worried	A Little	Somewhat	Much	Very Much Worried
0	1	2	3	4

7. To what extent do you consider your sleep problem to INTERFERE with your daily functioning (e.g. daytimefatigue, mood, ability to function at work/daily chores, concentration, memory, mood, etc.) CURRENTLY?
Not at allInterfering	A Little	Somewhat	Much	Very Much Interfering
0	1	2	3	4

For Hearing Healthcare Professionals