Sleep Assessment*

Sleep Assessment*
Patient Name*

First NameLast Name
Email*
example@example.com
Which Clinician asked you to fill out this form?

Mary Strayhorn Philips PNPSusan Swanson-Moore PNPJonathan Becker DOMichelle Cochran MDKelly Anderson PNPLeah Bowen PNPOther
Scale total (4 or 5 on any item suggests clinically significant insomnia)
How often in the past month did you have trouble falling asleep?*
How often in the past month wake up several times per night?*
How often in the past month have trouble staying asleep (including waking far too early)?*
How often in the past month wake up after your usual amount of sleep feeling tired and worn out?*
*adapted from Jenkins CD, Stanton BA, Niemcryk SJ, Rose RM. A scale for the estimation of sleep problems in clinical research. J Clin Epidemiol. 1988;41(4):313-21. doi: 10.1016/0895-4356(88)90138-2. PMID: 3351539.

https://pubmed.ncbi.nlm.nih.gov/3351539/
Should be Empty: