Week 3 Sleep Training

Please enter this information below from the paper form (Week 3 Self-Assessment Form) you have filled out. This data is completely anonymous. It will be used to improve the quality of this sleep training product as part of our Sleep Training Process and Quality Improvement Project. Upon submitting this form, you will be provided LINK to the next step for Week 1 of Sleep Training. When you Click Submit, wait for the link to appear to go to the next step (s). Thank you!

How long have you suffered from sleep problems (in months)? *

Age *

Gender *

Male

Female

WK 3 Insomnia Severity Index *

For each question, please select the number that best describes your answer. Please rate the CURRENT (i.e. LAST 7 days) SEVERITY of your insomnia problem(s). || 0=None; 1=Mild; 2=Moderate; 3=Severe; 4=Very Severe

0

1

2

3

4

Difficulty falling asleep

Difficulty staying asleep

Problems waking up too early

WK 3 Beliefs about Sleep *

1= strongly DISAGREE || 10= strongly AGREE ||| Several statements reflecting people’s beliefs and attitudes about sleep are listed below. Please indicate to what extent you personally agree or disagree with each statement. There is no right or wrong answer. For each statement, select a number that best reflects your personal experience. Consider the whole scale, rather than only the extremes of the continuum.

1

2

3

4

5

6

7

8

9

10

1. I need 8 hours of sleep to feel refreshed and function well during the day.

2. When I do not get proper amount of sleep on a given night, I need to catch up on the next day by napping or on the next night by sleeping longer.

3. I am concerned that chronic insomnia may have serious consequences for my physical health.

4. I am worried that I may lose control over my abilities to sleep.

5. After a poor night’s sleep, I know that it will interfere with my daily activities on the next day.

6. In order to be alert and function well during the day, I am better off taking a sleeping pill rather than having a poor night’s sleep.

7. When I feel irritable, depressed, or anxious during the day, it is mostly because I did not sleep well the night before.

8. When I sleep poorly on one night, I know that it will disturb my sleep schedule for the whole week.

9. Without an adequate night’s sleep, I can hardly function the next day.

10. I can’t ever predict whether I will have a good or poor night’s sleep.

11. I have little ability to manage the negative consequences of disturbed sleep.

12. When I feel tired, have no energy, or just seem not to function well during the day, it is generally because I did not sleep well the night before.

13. I believe that insomnia is essentially a result of a chemical imbalance.

14. I feel that insomnia is ruining my ability to enjoy life and prevents me from doing what I want.

15. Medication is probably the only solution to sleeplessness.

16. I avoid or cancel obligations (social, family, occupational) after a poor night’s sleep.