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.

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