Not during the past month (0)

Less than once a week (1)

Once or twice a week (2)

Three or more times a week (3)

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, including how often you have trouble sleeping because of this reason(s):