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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).

Insomnia Problem None Mild Moderate Severe Very Severe
1. Difficulty falling asleep
2. Difficulty staying asleep
3. Problems waking up too early
4. How SATISFIED/DISSATISFIED are you with your CURRENT sleep pattern?
Very Satisfied Satisfied Moderately Satisfied Dissatisfied Very Dissatisfied
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
6. How WORRIED/DISTRESSED are you about your current sleep problem?
Not at all Worried A Little Somewhat Much Very Much Worried
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
For Hearing Healthcare Professionals