Insomnia Questionnaire

Screens sleep problems by asking how often nights go badly, how many hours are actually slept and what daily habits surround them. Caffeine, alcohol, shift work and mood questions help a clinician read the pattern.

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What is your gender?

Female Male Non-binary Prefer not to say

What is your age range?

What is your marital status?

What is your employment status?

How many nights a week do you think you sleep badly?

How long have you had issues with your sleep?

Less than a month One to six months Six to twelve months More than a year

Are you a morning person?

Yes No Sometimes

Do you work night shifts?

Yes, regularly Occasionally No

How many hours of sleep do you get in 24 hours?

Who do you usually sleep with?

Do you smoke?

Yes, daily Occasionally I used to smoke Never

Do you usually drink alcohol?

Never Occasionally Weekly Daily

Do you usually drink coffee?

Never One cup a day Two to three cups a day More than three cups a day

How often do you exercise in a week?

Never Once a week Two to three times Four times or more

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