These questions pertain to your typical sleep patterns over the last month. Please respond based on the most accurate representation of your habits for the majority of days and nights during this period. Answer all questions.
Select the most appropriate response for each of the following questions. Be sure to answer all questions.
a) How often have you struggled to fall asleep within 30 minutes? (*)
b) How often have you experienced waking up in the middle of the night or early morning? (*)
c) How often have you had to get up to use the bathroom during the night? (*)
d) Have you experienced difficulty breathing comfortably? (*)
e) Have you coughed or snored loudly during sleep? (*)
f) Have you had bad dreams? (*)
g) Have you felt excessively hot? (*)
h) How often have you experienced pain? (*)
i) How frequently have you experienced difficulty staying awake while driving, eating meals, or engaging in social activities? (*)
j) How much of a challenge has it been for you to maintain enough enthusiasm to get things done? (*)
k) How frequently have you used medication (prescribed or over-the-counter) to aid your sleep? (*)
l) In the last month, how would you assess your overall sleep quality? (*)
Do you have a room-mate (RM) or bed partner (BP)? (*)
If you have a room-mate or bed partner, ask him/her how often in the past month you have had …
b) Long pauses between breaths while sleeping (*)
c) Legs twitching or jerking while you sleep (*)
d) Episodes of disorientation or confusion during sleep (*)
Other restlessness while you sleep, please describe
Indicate the likelihood of you dozing off or falling asleep in the following situations using the scale provided:
Sitting inactive in a public place (i.e. a theatre or meeting): (*)
As a passenger in a car for an hour without a break: (*)
Lying down to rest in the afternoon: (*)
Sitting and talking to someone: (*)
Sitting quietly after lunch with no alcohol: (*)
In a car while stopped for a few minutes in traffic: (*)
Please indicate the severity of your sleep-related issues by circling the appropriate number:
( None 0 | Moderate 1 | Severe 2 | Very Severe 3 )
Difficulty falling asleep (*)
Difficulty staying asleep (*)
Problem waking up too early (*)
2. Please express your satisfaction with your current sleep pattern by marking the appropriate number: (*)
3. To what extent do you perceive your sleep problem as affecting your daily functioning (e.g., daytime fatigue, work/chores, concentration, memory, mood, etc.)? (*)
4. To what extent do you believe your sleeping problem is noticeable to others in terms of your quality of life? (*)
5. Indicate your level of worry or distress regarding your current sleep problem: (*)
Lastly, could you please let us know what you're hoping to achieve through your treatment in the Sleep Program? (*)
Head Quarters: 210 – 221 Esplanade W, North Vancouver, BC V7M 3J3
Phone: (604) 220-8866 | 
Monday—Friday: 9:00 AM-7:30 PM
