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The Pittsburgh Sleep Quality Index (PSQI)
Instructions: The following questions relate to your usual sleep habits during the past months only (OR the time AFTER your accident). Your answers should indicate the most accurate reply for the majority of days and nights in the past months. Please answer all questions. During the past month...
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* Indicates required question
Today's Date:
*
MM
/
DD
/
YYYY
Full Name:
*
Your answer
Date of Accident/Injury:
*
MM
/
DD
/
YYYY
Signature (initials)
*
Your answer
1) When have you usually gone to bed?
*
Your answer
2) How long (in minutes) has it taken you to fall asleep each night?
*
Your answer
3) When have you usually gotten up in the morning?
*
Your answer
4) How many hours of actual sleep do you get a night? (This may be different than the number of hours you spend in bed)
*
Your answer
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 past month (0)
Less than once a week (1)
Once or twice a week (2)
Three or more times a week (3)
b. Wake up in the middle of the night or early morning
*
Not during the past month (0)
Less than once a week (1)
Once or twice a week (2)
Three or more times a week (3)
c. Have to get up to use the bathroom
*
Not during the past month (0)
Less than once a week (1)
Once or twice a week (2)
Three or more times a week (3)
d. Cannot breathe comfortably
*
Not during the past month (0)
Less than once a week (1)
Once or twice a week (2)
Three or more times a week (3)
e. Cough or snore loudly
*
Not during the past month (0)
Less than once a week (1)
Once or twice a week (2)
Three or more times a week (3)
f. Feel too cold
*
Not during the past month (0)
Less than once a week (1)
Once or twice a week (2)
Three or more times a week (3)
g. Feel too hot
*
Not during the past month (0)
Less than once a week (1)
Once or twice a week (2)
Three or more times a week (3)
h. Have bad dreams or night terrors
*
Not during the past month (0)
Less than once a week (1)
Once or twice a week (2)
Three or more times a week (3)
i. Have pain
*
Not during the past month (0)
Less than once a week (1)
Once or twice a week (2)
Three or more times a week (3)
j. Other reason(s), please describe, including how often you have had trouble sleeping because of this reason(s)
*
Your answer
Choose the best option pertaining to the above answer you wrote in the above (j.)
Not during the past month (0)
Less than once a week (1)
Once or twice a week (2)
Three or more times a week (3)
Clear selection
6. During the past month, how often have you had trouble staying awake while driving, eating meals or engaging in social activity?
*
Not during the past month (0)
Less than once a week (1)
Once or twice a week (2)
Three of more times a week (3)
7. During the past month, how often have you taken medicine (prescribed or over the counter) to help you sleep?
*
Not during the past month (0)
Less than once a week (1)
Once or twice a week (2)
Three of more times a week (3)
8. Having significant problems keeping up enthusiasm to get things done
*
Not during the past month (0)
Less than once a week (1)
Once or twice a week (2)
Three of more times a week (3)
9. During the past month, how would you rate your sleep quality overall?
*
Very good (1)
Fairly good (2)
Fairly bad (2)
Very bad (3)
Please feel free to add anything else you'd like us to understand about your current sleep health (e.g. I can't sleep on my side/stomach, I have night terrors, I am sleeping too much and can't get out of bed in the morning, etc.).
Your answer
Completed by provider ONLY:
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