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Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Questionnaires

Pittsburgh Sleep Quality Index Tool

Pittsburgh Sleep Quality Index Tool - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Questionnaires


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AM
Subject’s Initials ID# Date Time PM


PITTSBURGH SLEEP QUALITY INDEX


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.


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

BED TIME ___________

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

NUMBER OF MINUTES ___________

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

GETTING UP TIME ___________

4. 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.)

HOURS OF SLEEP PER NIGHT ___________


For each of the remaining questions, check the one best response. Please answer all questions.

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

a) Cannot get to sleep within 30 minutes

Not during the Less than Once or twice Three or more
past month_____ once a week_____ a week_____ times a week_____

b) Wake up in the middle of the night or early morning

Not during the Less than Once or twice Three or more
past month_____ once a week_____ a week_____ times a week_____

c) Have to get up to use the bathroom

Not during the Less than Once or twice Three or more
past month_____ once a week_____ a week_____ times a week_____


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d) Cannot breathe comfortably

Not during the Less than Once or twice Three or more
past month_____ once a week_____ a week_____ times a week_____

e) Cough or snore loudly

Not during the Less than Once or twice Three or more
past month_____ once a week_____ a week_____ times a week_____

f) Feel too cold

Not during the Less than Once or twice Three or more
past month_____ once a week_____ a week_____ times a week_____

g) Feel too hot

Not during the Less than Once or twice Three or more
past month_____ once a week_____ a week_____ times a week_____

h) Had bad dreams

Not during the Less than Once or twice Three or more
past month_____ once a week_____ a week_____ times a week_____

i) Have pain

Not during the Less than Once or twice Three or more
past month_____ once a week_____ a week_____ times a week_____

j) Other reason(s), please describe__________________________________________

__________________________________________________________________________

How often during the past month have you had trouble sleeping because of this?

Not during the Less than Once or twice Three or more
past month_____ once a week_____ a week_____ times a week_____


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

Very good ___________

Fairly good ___________

Fairly bad ___________

Very bad ___________



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

Not during the Less than Once or twice Three or more
past month_____ once a week_____ a week_____ times a week_____


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

Not during the Less than Once or twice Three or more
past month_____ once a week_____ a week_____ times a week_____


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

No problem at all __________

Only a very slight problem __________

Somewhat of a problem __________

A very big problem __________


10. Do you have a bed partner or room mate?

No bed partner or room mate __________

Partner/room mate in other room __________

Partner in same room, but not same bed __________

Partner in same bed __________

If you have a room mate or bed partner, ask him/her how often in the past month you
have had . . .

a) Loud snoring

Not during the Less than Once or twice Three or more
past month_____ once a week_____ a week_____ times a week_____

b) Long pauses between breaths while asleep

Not during the Less than Once or twice Three or more
past month_____ once a week_____ a week_____ times a week_____

c) Legs twitching or jerking while you sleep

Not during the Less than Once or twice Three or more
past month_____ once a week_____ a week_____ times a week_____

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© 1989, University of Pittsburgh. All rights reserved. Developed by Buysse,D.J., Reynolds,C.F., Monk,T.H., Berman,S.R., and
Kupfer,D.J. of the University of Pittsburgh using National Institute of Mental Health Funding.

Buysse DJ, Reynolds CF, Monk TH, Berman SR, Kupfer DJ: Psychiatry Research, 28:193-213, 1989.
d) Episodes of disorientation or confusion during sleep

Not during the Less than Once or twice Three or more
past month_____ once a week_____ a week_____ times a week_____

e) Other restlessness while you sleep; please describe__________________________________

___________________________________________________________________________

Not during the Less than Once or twice Three or more
past month_____ once a week_____ a week_____ times a week_____