Insomnia Questionnaire
What is your gender?
Female
Male
Non-binary
Prefer not to answer
What is your age range?
16-26
27-37
38-48
49-59
60+
What is your marital status?
Single
Married
Divorced
Widowed
Prefer not to answer
What is your employment status?
Employed full time
Employed part time
Self-employed
Unemployed
Not looking for a job
Student
Prefer not to answer
How often has poor sleep troubled you in the last month?
Never
1
2
3
4
Always
5
1 is Never, 5 is Always
How often have you not been able to sleep in the last month?
Never
1
2
3
4
Always
5
1 is Never, 5 is Always
How many nights do you think you get poor sleep in a week?
How often do you feel sleepy in the day time while working?
Never
1
2
3
4
Always
5
1 is Never, 5 is Always
For how long do you think you have had issues with your sleep?
Less than a month
1-3 months
4-6 months
6-9 months
10-12 months
More than a year
Are you a morning person?
Yes
No
Neither
Do you work in night shifts?
Yes
No
How many hours of sleep do you get in 24 hours?
Who do you sleep with usually?
Alone
With partner
With roommates
With parents
With children
Do you smoke?
Yes
No
Do you usually drink alcohol?
Yes
No
Do you usually have coffee?
Yes
No
How often do you exercise in a week?
I don’t exercise at all
Once a week
2-3 time a week
4-5 times a week
5-6 times a week
Everyday
How often do you feel depressed?
Never
1
2
3
4
Always
5
1 is Never, 5 is Always
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