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 |
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b. Wake up in the middle of the night or early morning |
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c. Have to get up to use the bathroom |
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d. Cannot breathe comfortably |
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e. Cough or snore loudly |
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f. Feel too cold |
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g. Feel too hot |
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h. Have bad dreams |
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i. Have pain |
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j. other reason(s), please describe: |
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How often during the past month you have been trouble sleeping because of this? |
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| Very good | Fairly good | Fairly bad | Very bad |
6. During the past month, how would you rate your sleep quality overall? |
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| 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”) |
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8. During the past month, how often have you had trouble staying awake while driving, eating meals, or engaging in social activity |
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