Welcome to your Pittsburgh Sleep Quality Index (PSQI)!

Instructions: The following questions relate to your usual sleep habits during the past month only. Your answers should indicate the most accurate reply for the majority of days and nights in the past month. Please answer all questions.


During the past month, what time have you usually gone to bed at night?


During the past month, how long (in minutes) has it usually taken you to fall asleep each night?


During the past month, what time have you usually gotten up in the morning?


During the past month, how many hours of actual sleep did you get at night? (This may be different than the number of hours you spent in bed)


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



Cannot get to sleep within 30 minutes.


Wake up in the middle of the night or early morning

Have to get up to use the bathroom.

Cannot breathe comfortably.

Cough or snore loudly.

Feel too cold

Feel too hot

Have bad dreams

Have pain

Other reason (s), please describe:


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

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

During the past month, how much of a problem has it been for you to keep up enough enthusiasm to get things done?

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

Do you have a bed partner or roommate?

If you have a roommate or partner, ask him/her how often in the past month you have had:



Loud snoring


Long pauses between breaths while asleep

Legs twitching or jerking while you sleep

Episodes of disorientation or confusion during sleep

Other restlessness while you sleep, please describe:



Name


Email


Phone Number