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In-Lab Sleep Studies
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Order Travel CPAP
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For Providers
X
INSOMNIA QUIZ
Take this short insomnia index evaluation to see where your sleep difficulty fits. please rate the CURRENT (i.e. last 2 weeks) SEVERITY of your sleep problems.
INSOMNIA QUIZ
First Name*
Last Name*
Email address*
Phone Number*
Do You Live in Alaska*
Yes
No
City*
1. Difficulty Falling Asleep
Please Select
None - 0
Mild - 1
Moderate - 2
Severe - 3
Very Severe - 4
2. Difficulty Staying Asleep
Please Select
None - 0
Mild - 1
Moderate - 2
Severe - 3
Very Severe - 4
3. Problems Waking Up Too Early
Please Select
None - 0
Mild - 1
Moderate - 2
Severe - 3
Very Severe - 4
4. How SATISFIED/DISSATISFIED are you with your CURRENT sleep pattern?*
Very Satisfied - 0
Satisfied - 1
Moderately Satisfied - 2
Dissatisfied - 3
Very Dissatisfied - 4
5. How NOTICEABLE to others do you think your sleep problem is in terms of impairing the quality of your life?*
Not at all Noticeable - 0
A Little - 1
Somewhat - 2
Much - 3
Very Much Noticeable - 4
6. How WORRIED/DISTRESSED are you about your current sleep problem?*
Not at all Noticeable - 0
A Little - 1
Somewhat - 2
Much - 3
Very Much Noticeable - 4
7. To what extent do you consider your sleep problem to INTERFERE with your daily functioning (e.g. daytime fatigue, mood, ability to function at work/daily chores, concentration, memory, mood, etc.) CURRENTLY?*
Not at all Noticeable - 0
A Little - 1
Somewhat - 2
Much - 3
Very Much Noticeable - 4
Guidelines for Scoring/Interpretation:
Add scores for all seven questions 1 + 2 + 3 + 4 + 5 +6 + 7) = your total score
Total score categories:
0–7 = No clinically significant insomnia
8–14 = Subthreshold insomnia
15–21 = Clinical insomnia (moderate severity)
22–28 = Clinical insomnia (severe)
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About ASC
Who We are
Get to Know Us
Meet Our Staff
Locations
Services
Sleep Disorders
In-Lab Sleep Studies
Home Sleep Testing
Pediatrics
CPAP Therapy
Follow-UP/SleepN
Telemedicine
Sleep Education
Sleep Blogs
FAQ’s
Moms Everyday TV
Patient Resource Page
On-the-job Safety
For Patients
Self-Referral Form
Forms & Packets
Request Appointment
Order CPAP Supplies
Order Travel CPAP
Pediatric Assessment
Employee Safety / DOT
Pay Your Bill
— — Notice of Breach of Personal Information
For Providers