LEVEL 2—Sleep Disturbance

*PROMIS—Sleep Disturbance—Short Form

Name:

Age:

Female

Sex:Male

Date:

Date

If the measure is being completed by an informant, what is your relationship with the individual receiving care?

In a typical week, approximately how much time do you spend with the individual receiving care?

Instructions to patient: On the DSM-5 Level 1 cross-cutting questionnaire that you just completed, you indicated that during the past

2 weeks you (the individual receiving care) have been bothered by “problems with sleep that affected your sleep quality over all” at a mild or greater level of severity. The questions below ask about these feelings in more detail and especially how often you (the

individual receiving care) have been bothered by a list of symptoms during the past 7 days. Please respond to each item by marking (1-5) one box per row.

In the past seven (7) days

1) My sleep was restless

2) I was satisfied with my sleep

3) My sleep was refreshing

4) I had difficulty falling asleep

In the past seven (7) days

5) I had trouble staying asleep

6) I had trouble sleeping

7) I got enough sleep

In the past seven (7) days

8) My sleep quality was

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LEVEL 2—Sleep Disturbance—Adult

Sex: