CURHAN Base Protocol Sleep Questionnaire

Adapted from Framingham Heart Study 2013


 

EPWORTH SLEEPINESS SCALE

What is the chance that you would doze off or fall asleep (not just “feel tired”) in each of the following situations? (Circle one response for each situation. If you are never or rarely in the situation, please give your best guess for that situation)
  None Slight Moderate High
Sitting and reading 0 1 2 3
Watching TV 0 1 2 3
Sitting inactive in a public place (such as theater or a meeting) 0 1 2 3
Riding as a passenger in a car for an hour without a break 0 1 2 3
Lying down to rest in the afternoon when circumstances permit 0 1 2 3
Sitting and talking to someone 0 1 2 3
Sitting quietly after a lunch without alcohol 0 1 2 3
In a car, while stopped in traffic for a few minutes 0 1 2 3


 

FORD INSOMNIA RESPONSE TO STRESS TEST (FIRST)

When you experience the following situations, how likely is it for you to have difficulty sleeping?Circle an answer even if you have not experienced these situations recently.
Not likely Somewhat likely Moderately likely Very likely
Before an important meeting the next day 0 1 2 3
After a stressful experience during the day 0 1 2 3
After a stressful experience in the evening 0 1 2 3
After getting bad news during the day 0 1 2 3
After watching a frightening movie or TV show 0 1 2 3
After having a bad day at work 0 1 2 3
After an argument 0 1 2 3
Before having to speak in public 0 1 2 3
Before going on vacation the next day 0 1 2 3

 

Sleep Disturbance Questionnaire

 B

 


 

Functional Outcomes of Sleep Questionnaire

  1. Do you generally have difficulty concentrating on the things you do because you are sleepy or tired?
  2. Do you generally have difficulty remembering things because you are sleepy or tired?
  3. Do you have difficulty finishing a meal because you become sleepy or tired?
  4. Do you have difficulty working on a hobby (for example: sewing, collecting, gardening) because you are sleepy or tired?
  5. Do you have difficulty doing work around the house (for example: cleaning house, doing laundry, taking out the trash, repair work) because you are sleepy or tired?
  6. Do you have difficulty operating a motor vehicle for short distances (less than 100 miles) because you become sleepy or tired?
  7. Do you have difficulty operating a motor vehicle for long distances (greater than 100 miles) because you become sleepy or tired?
  8. Do you have difficulty getting things done because you are too sleepy or tired to drive or take public transportation?
  9. Do you have difficulty taking care of financial affairs and doing paperwork (for example: writing checks, paying bills, keeping financial records, filling out tax forms, etc.) because you are sleepy or tired?
  10. Do you have difficulty performing employed or volunteer work because you are sleepy or tired?
  11. Do you have difficulty maintaining a telephone conversation because you become sleepy or tired?
  12. Do you have difficulty visiting with your family or friends in your home because you become sleepy or tired?
  13. Do you have difficulty visiting with your family or friends in their home because you become sleepy or tired?
  14. Do you have difficulty doing things for your family or friends because you are too sleepy or tired?
  15. For Question 15 answer using only 1, 2, 3 or 4 (1 being the least, 4 being the most) Has your relationship with family, friends or work colleagues been affected because you are sleepy or tired?
  16. Do you have difficulty exercising or participating in a sporting activity because you are too sleepy or tired?
  17. Do you have difficulty watching a movie or videotape because you become sleepy or tired?
  18. Do you have difficulty enjoying the theater or a lecture because you become sleepy or tired?
  19. Do you have difficulty enjoying a concert because you become sleepy or tired?
  20. Do you have difficulty watching television because you are sleepy or tired?
  21. Do you have difficulty participating in religious services, meetings or a group or club because you are sleepy or tired?
  22. Do you have difficulty being as active as you want to be in the evening because you are sleepy or tired?
  23. Do you have difficulty being as active as you want to be in the morning because you are sleepy or tired?
  24. Do you have difficulty being as active as you want to be in the afternoon because you are sleepy or tired?
  25. Do you have difficulty keeping pace with others your own age because you are sleepy or tired?
  26. For Question 26 only, answer using the scale below.How would you rate your general level of activity?1 = Very Low; 2 = Low; 3 = Medium; 4 = High
  27. Has your intimate or sexual relationship been affected because you are sleepy or tired?
  28. Has your desire for intimacy or sex been affected because you are sleepy or tired?
  29. Has your ability to become sexually aroused been affected because you are sleepy or tired?
  30. Has your ability to have an orgasm been affected because you are sleepy or tired?

 

CURHAN Sleep Questionnaire Protocol, March 9, 2016

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About 陈馨雨

2014级本科生
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