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SleepMed Inc. - SleepMed Insomnia Index (SMII) Questionnaire




This is a test to assess, in general, how you are feeling about your sleep. Answer the following questions rating how you feel about your sleep using a "0-4" point scale -- with "0" representing no problem with your sleep and "4" representing a big problem with how you feel about the quality of your sleep.

0 = No Problem with My Sleep
1 = Slight Problem with My Sleep
2 = Moderate Problem with My Sleep
3 = Moderately Severe Problem with My Sleep
4 = Big Problem with My Sleep Affecting All Parts of My Life

Select the answer that best describes your sleep.

Overall, describe your satisfaction with your sleep?
0   1   2   3   4  
How easy is it for you to fall asleep?
0   1   2   3   4  
How worried are you that you won't be able to get to sleep?
0   1   2   3   4  
Are you easily awakened by sounds/noises in the night?
0   1   2   3   4  
When you sleep in a strange place or a bed other than your own, how much trouble do you have trying to fall asleep?
0   1   2   3   4  
Is your sleep disturbed with frequent awakenings?
0   1   2   3   4  
Can you fall back asleep if you awaken during the night?
0   1   2   3   4  
Are you rested the next day after your night's sleep?
0   1   2   3   4  
Do you think you are getting enough hours of sleep each night?
0   1   2   3   4  
How much does the quality of the sleep affect your next day function (ie fatigue, mood, irritability)?
0   1   2   3   4  
 


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