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Sleep Assessment (SDS-CL-25 v1)
delivers to Jane Rekas, LCSW
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Answer all questions for what has been typical for you for the last 3 months.
first name:
Your answer
email:
Your answer
Do you have:
Sleep Apnea
Narcolepsy
Sleep Walking
History of Sleep Terrors
Other:
Work Shift
First (9 to 5)
Second (4 to midnight)
Third (midnight to 8am)
PTE (less than 3 days a week)
Work at Home
Retired (don't work)
Disabled (don't work)
Unemployed
Other:
Do you regularly have a bed partner? (3 or more days a week)
Yes
No
Other:
Clear selection
1) My work or other activities prevent me from getting at least 7 hours of sleep
0 = Never
1 = Once a Month
2 = 1 to 3 Times a Week
3 = 3 to 5 Times a Week
Other:
2) My bedtime or waketime varies by more than 3 hours
0 = Never
1 = Once a Month
2 = 1 to 3 Times a Week
3 = 3 to 5 Times a Week
Other:
3) It takes me 30 minutes or more to fall asleep
0 = Never
1 = Once a Month
2 = 1 to 3 Times a Week
3 = 3 to 5 Times a Week
Other:
4) I am awake for 30 minutes or more during the night
0 = Never
1 = Once a Month
2 = 1 to 3 Times a Week
3 = 3 to 5 Times a Week
Other:
5) I wake up 30 or more minutes before I have to and can't fall back asleep
0 = Never
1 = Once a Month
2 = 1 to 3 Times a Week
3 = 3 to 5 Times a Week
Other:
6) I am tired, fatigued, or sleep during the day
0 = Never
1 = Once a Month
2 = 1 to 3 Times a Week
3 = 3 to 5 Times a Week
Other:
7) I sleep better if I go to bed before 9pm and wakeup before 4:30am
0 = Never
1 = Once a Month
2 = 1 to 3 Times a Week
3 = 3 to 5 Times a Week
Other:
8) I sleep better if I go to bed late (after 1am) and wakeup late (after 9am)
0 = Never
1 = Once a Month
2 = 1 to 3 Times a Week
3 = 3 to 5 Times a Week
Other:
9) I am prone to fall asleep at inappropriate times or places
0 = Never
1 = Once a Month
2 = 1 to 3 Times a Week
3 = 3 to 5 Times a Week
Other:
10) I snore
0 = Never
1 = Once a Month
2 = 1 to 3 Times a Week
3 = 3 to 5 Times a Week
Other:
11) I wake up with a dry mouth in the morning (cotton mouth)
0 = Never
1 = Once a Month
2 = 1 to 3 Times a Week
3 = 3 to 5 Times a Week
Other:
12) My snoring is so loud that my bed partner complains
0 = Never or Not applicable
1 = Once a Month
2 = 1 to 3 Times a Week
3 = 3 to 5 Times a Week
Other:
13) I have been told that I stop breathing in my sleep
0 = Never
1 = Once a Month
2 = 1 to 3 Times a Week
3 = 3 to 5 Times a Week
Other:
14) I wake up choking or gasping for air
0 = Never
1 = Once a Month
2 = 1 to 3 Times a Week
3 = 3 to 5 Times a Week
Other:
15) I feel uncomfortable sensations in my legs, especially when sitting or lying down, that are relieved by moving them
0 = Never
1 = Once a Month
2 = 1 to 3 Times a Week
3 = 3 to 5 Times a Week
Other:
16) I have an urge to move my legs that is worse in the evening and nights
0 = Never
1 = Once a Month
2 = 1 to 3 Times a Week
3 = 3 to 5 Times a Week
Other:
17) I wake up frequently during the night for no reason
0 = Never
1 = Once a Month
2 = 1 to 3 Times a Week
3 = 3 to 5 Times a Week
Other:
18) When angered, humored, frightened, I experience sudden muscle weakness
0 = Never
1 = Once a Month
2 = 1 to 3 Times a Week
3 = 3 to 5 Times a Week
Other:
19) When falling asleep or waking up, I experience scary dream like images
0 = Never
1 = Once a Month
2 = 1 to 3 Times a Week
3 = 3 to 5 Times a Week
Other:
20) When I am first awakening, I feel like I can't move
0 = Never
1 = Once a Month
2 = 1 to 3 Times a Week
3 = 3 to 5 Times a Week
Other:
21) I have nightmares
0 = Never
1 = Once a Month
2 = 1 to 3 Times a Week
3 = 3 to 5 Times a Week
Other:
22) For no reason, I awaken suddenly, startled and feeling afraid
0 = Never
1 = Once a Month
2 = 1 to 3 Times a Week
3 = 3 to 5 Times a Week
Other:
23) I have been told that I walk, talk, eat, act strangely or violently when I sleep
0 = Never
1 = Once a Month
2 = 1 to 3 Times a Week
3 = 3 to 5 Times a Week
Other:
24) I grind my teeth or clench my jaw during sleep
0 = Never
1 = Once a Month
2 = 1 to 3 Times a Week
3 = 3 to 5 Times a Week
Other:
25) My sleep difficulties interfere with my daily activities
0 = Never
1 = Once a Month
2 = 1 to 3 Times a Week
3 = 3 to 5 Times a Week
Other:
SDS-CL-25 Interpretation
Insomnia Disorder:
scores of 3 or 4
Q3 or Q4 or Q5 AND
Q6 or Q9 or Q25
Other:
F51.01 Insomnia criteria:
A predominant complaint of dissatisfaction with sleep quantity or quality, associated with one (or more) of the following symptoms:
1. Difficulty initiating sleep. (In children, this may manifest as difficulty initiating sleep without caregiver intervention.)
2. Difficulty maintaining sleep, characterized by frequent awakenings or problems returning to sleep after awakenings. (In children, this may manifest as difficulty returning to sleep without caregiver intervention.)
3. Early-morning awakening with inability to return to sleep.
B. The sleep disturbance causes clinically significant distress or impairment in social, occupational, educational, academic, behavioral, or other important areas of functioning.
C. The sleep difficulty occurs at least 3 nights per week.
D. The sleep difficulty is present for at least 3 months.
E. The sleep difficulty occurs despite adequate opportunity for sleep.
F. The insomnia is not better explained by and does not occur exclusively during the course of another sleep-wake disorder (e.g., narcolepsy, a breathing-related sleep disorder, a circadian rhythm sleep-wake disorder, a parasomnia).
G. The insomnia is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication).
H. Coexisting mental disorders and medical conditions do not adequately explain the predominant complaint of insomnia.
Other:
Advanced Sleep Phase Disorder:
scores of 3 or 4
Q7 + Q5 AND
Q6 or Q9 or Q25
Other:
Delayed Sleep Phase Disorder:
scores of 3 or 4
Q8 + Q3 AND
Q6 or Q9 or Q25
Other:
Circadian Rhythm Disorders
definitions
Circadian Rhythm Disorders: Symptoms, Treatment & Types (clevelandclinic.org)
A persistent or recurrent pattern of sleep disruption that is primarily due to an alteration of the circadian system or to a misalignment between the endogenous circadian rhythm and the sleep-wake schedule required by an individual’s physical environment or social or professional schedule.
Jet lag disorder. You’ve recently traveled to a different time zone, which takes you out of sync with the day/night schedule you’re used to.
G47.21 Delayed sleep-wake phase disorder (DSWPD). Your sleep/wake schedule is much later than the average person. It’s more common in children and teenagers. A pattern of delayed sleep onset and awakening times, with an inability to fall asleep and awaken at a desired or conventionally acceptable earlier time.
G47.22 Advanced sleep-wake phase disorder (ASWPD). You go to bed earlier and wake earlier than the average person. A pattern of advanced sleep onset and awakening times, with an inability to remain awake or asleep until the desired or conventionally acceptable later sleep or wake times.
G47.23 Irregular sleep-wake rhythm disorder (ISWRD). Your sleep and wake times happen at unpredictable, disorganized intervals. This usually happens to people with dementia or other degenerative brain diseases. A temporally disorganized sleep-wake pattern, such that the timing of sleep and wake periods is variable throughout the 24-hour period.
G47.24 Non-24-hour sleep-wake rhythm disorder (N24SWD). Your circadian rhythm is predictable, but it isn’t 24 hours like most people’s. It’s usually longer, but it could be shorter. A pattern of sleepwake cycles that is not synchronized to the 24-hour environment, with a consistent daily drift (usually to later and later times) of sleep onset and wake times.
G47.26 Shift work sleep disorder (SWSD). You have trouble adjusting your circadian rhythm to your work schedule. You’re more prone to this if you work night shifts.
Other:
(optional)
Items to consider:
scores of 3 or 4
Insomnia disorder (Q3 or Q4 or Q5) + (Q6 or Q9 or Q25)
Q17 may also be highly endorsed
Advanced sleep phase syndrome Q7 + Q5 + (Q6 or Q9 or Q25)
Delayed sleep phase syndrome Q8 + Q3 + (Q6 or Q9 or Q25)
Obstructive sleep apnea Q10 – Q14 + (Q6 or Q9 or Q25)
Restless legs syndrome/periodic limb movement disorder Q15 – Q17 + (Q6 or Q9 or Q25)
Narcolepsy Q18 – Q20 + Q9 (also Q6 or Q25)
Nightmare disorder Q21 + Q25
Night terror disorder Q22
REM sleep behavior disorder Q23
Sleep-related TMJ Q24
Sleep insufficiency disorder H4 and H5 + Q1 + (Q6 or Q9 or Q25)
Shiftwork sleep disorder H1 + (Q1 or Q2 or Q3) or (H4 and/or Q1) + (Q6 or Q9 or Q25)
Excessive daytime sleepiness non-specific Q9
Fatigue Q6
Total sleep time (TST) H4
Time in bed (TIB) H5
Sleep efficiency (%) 100 × TST / TIB = 100 × H4 / H5
Shift worked H1
Informant H3-can verify Q10, Q12–15, Q23
Normal short sleep variant H4 without (Q6 or Q9 or Q25)
General concern (Q6 or Q9 or Q25) without other Q’s endorsed
Identification
of individual sleep disorders may be deemed appropriate for follow up if one or more endorsements within the category has a response of 3 or 4 check.
Your answer
Severity
of the individual sleep disorders: sum the individual item scores for each category and divide by the number of items to yield an average score.
Your answer
Cumulative morbidity:
sum all of the endorsements across the 25 items.
Your answer
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