For the following, please select the number that best describes your sleep for the last two weeks.

• Please rate the current (i.e., last 2 weeks) SEVERITY of your insomnia problem - difficulty falling asleep

  • None
  • Mild
  • Moderate
  • Severe
  • Very

• Please rate the current (i.e., last 2 weeks) SEVERITY of your insomnia problem - difficulty staying asleep

  • None
  • Mild
  • Moderate
  • Severe
  • Very

• Please rate the current (i.e., last 2 weeks) SEVERITY of your insomnia problem - problem waking up too early

  • None
  • Mild
  • Moderate
  • Severe
  • Very

• How satisfied/dissatisfied are you with your current sleep pattern?

  • Very Dissatisfied
  • Dissatisfied
  • Somewhat Satisfied
  • Satisfied
  • Very Satisfied

• To what extent do you consider your sleep problem to INTERFERE with your daily functioning (e.g., daytime fatigue, ability to function at work/daily chores, concentration, memory, mood, etc.).

  • Not at all Interfering
  • A Little
  • Somewhat
  • Much
  • Very Much Interfering

• How NOTICEABLE to others do you think your sleeping problem is in terms of impairing the quality of your life?

  • Not at all Noticeable
  • Barely
  • Somewhat
  • Much
  • Very Much Noticeable

• How WORRIED/distressed are you about your current sleep problem?

  • Not at all
  • A Little
  • Somewhat
  • Much
  • Very Much