CBT-I Sleep History Questionnaire
How did you hear about this program?
1. How many nights per week do you usually have difficulty falling asleep?
2. On these nights how long does it usually take you to fall asleep after going to bed?
3. How many nights per week do you wake up in the middle of the night and have difficulty falling back to sleep?
3a. On the average, how many times do you wake up on these nights?
3b. How long are you awake during the night?
4. How often do you wake up early in the morning, before your scheduled wake time, and are unable to return to sleep?
5. On nights when you have insomnia, approximately how long do you sleep each night?
6. On nights when you don't have insomnia, how long do you sleep?
7. How long would you like to be able to sleep each night?
8. How long have you had sleep problems?
9. Is your sleep problem sometimes worse than other times?
10. Was the onset of your sleep problem related to any specific event?
11. What do you do to relax prior to bedtime?
12a. What time do you get into bed at night?
12b. What time do you turn off the lights to go to sleep?
12c. What time do you get out of bed in the morning?
13. Do you use your bed for activities other than sleep or sexual activity?
14a. At this time, how much stress would you say there is in your life? Please select the appropriate number.
1 is No stress, 10 is High Stress
14b. Please list significant stressors during the past 18 months:
14c. Have you ever been abused, the victim of a crime, or experienced a trauma?
14d. What resources do you have for emotional support? Select all that apply.
15a. Have you received psychological treatment (such as psychotherapy) in the past for depression, an anxiety disorder (such as panic disorder), alcohol problems, or other problems?
15b. If you selected "Yes" for 15a, what were you treated for?
16. Are you currently in treatment with any of the following? Select all that apply.
17. Have you experienced either depressed mood or a loss of interest in pleasure or pleasurable activities for a two-week period in the past 6 months?
18a. How long have you been in therapy?
18b. How often are you in therapy?
18c. What is the focus of your treatment?
19. How often is your sleep disturbed by environmental factors such as traffic, neighbors, or family members?
20. On weekends or your days off, do you sleep more than an hour later than your usual wake up time?
21. How many times per week do you take naps?
22a. Do you engage in some kind of regular physical exercise?
22b. If you answered "Yes" to 22a, describe the kind, frequency, and time of day:
23a. Have you previously, or do you currently, practice any type of relaxation technique?
23b. If you answered "Yes" to 23a, describe the type:
24. How many cups or glasses of caffeinated beverages (e.g., coffee, tea, or cola) do you drink in a day? Please list the type and number of cups/glasses.
25. How many days a week do you drink caffeinated beverages after 4:00 p.m.?
26. How often do you use alcohol to aid sleep?
27. How often and what amounts of alcohol do you drink? Do you use recreational drugs?
28a. Does difficulty sleeping ever affect your mood or functioning during the day?
28b. If you answered "Yes" to 28a, describe how your mood or functioning is affected:
29. Are you sleepy during the day?
30a. Have you recently taken any prescription or over-the-counter medication for sleeping problems?
30b. If you answered "Yes" to 30a, what medication(s) and amount(s) are you taking?
30c. How many nights a week do you usually take this medication?
30d. How long have you been taking sleeping medication?
31. Do you snore?
32. Do you ever wake up in the night and feel unable to breathe?
33. Do your legs ever jerk repeatedly or feel restless after you go to bed at night?
34a. Are you currently taking any other medication(s)?
34b. If you answered "Yes" to 34a, what medication is it?
34c. What illness was it prescribed for?
35. Is there a history of sleeping difficulties in your family?
36a. Have you previously been evaluated or treated for sleeping problems?
36b. If you answered "Yes" to 36a, please describe:
37a. Have you fried any self-help remedies for your sleeping problems?
37b. If you answered "Yes" to 37a, please describe:
Should be Empty: