5. During the past month, how often have you had trouble sleeping because you…

Not during

the past month

Less than

once a week

Once or twice a

week

Three or more times a week

a. Cannot get to sleep within 30 minutes

b. Wake up in the middle of the night or early morning

c. Have to get up to use the bathroom

d. Cannot breathe comfortably

e. Cough or snore loudly

f. Feel too cold

g. Feel too hot

h. Have bad dreams

i. Have pain

j. other reason(s), please describe:

How often during the past month you have been trouble sleeping because of this?

Very good

Fairly good

Fairly

bad

Very

bad

6. During the past month, how would you rate your sleep quality overall?

Not during the past month

Less than once a week

Once or twice a week

Three or more times a week

7. During the past month, how often have you taken medicine to help you sleep (prescribed or “over the counter”)

8. During the past month, how often have you had trouble staying awake while driving, eating meals, or engaging in social activity