LEVEL 2—Sleep Disturbance

LEVEL 2—Sleep Disturbance—Adult
*PROMIS—Sleep Disturbance—Short Form
Name:
Age:
Sex:
Female
Sex:Male
Date:
MonthDayYear
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