Sleep Quality Scale

Name *

First

Last

Email *

Phone

Date (mm/dd/yr)

I have difficulty falling asleep

Rarely
Sometimes
Often
Almost Always

I fall into a deep sleep

Rarely
Sometimes
Often
Almost Always

I wake up while sleeping

Rarely
Sometimes
Often
Almost Always

I have difficulty getting back to sleep once I wake up in the middle of the night

Rarely
Sometimes
Often
Almost Always

I wake up easily becasue of noise

Rarely
Sometimes
Often
Almost Always

I toss and turn

Rarely
Sometimes
Often
Almost Always

I never go back to sleep after awaking during sleep

Rarely
Sometimes
Often
Almost Always

I feel refreshed after sleep

Rarely
Sometimes
Often
Almost Always

I feel unlikely to sleep after sleep

Rarely
Sometimes
Often
Almost Always

Poor sleep gives me headaches

Rarely
Sometimes
Often
Almost Always

Poor sleep makes me irritated

Rarely
Sometimes
Often
Almost Always

I would like to sleep more after waking up

Rarely
Sometimes
Often
Almost Always

My sleep hours are enough

Rarely
Sometimes
Often
Almost Always

Poor sleep makes me loose my appetite

Rarely
Sometimes
Often
Almost Always

Poor sleep makes it hard for me to think

Rarely
Sometimes
Often
Almost Always

I feel vigorous after sleep

Rarely
Sometimes
Often
Almost Always

Poor sleep makes me lose interest in work or others

Rarely
Sometimes
Often
Almost Always

My fatigue is relieved after sleep

Rarely
Sometimes
Often
Almost Always

Poor sleep causes me to make mistakes at work

Rarely
Sometimes
Often
Almost Always

I am satisfied with my sleep

Rarely
Sometimes
Often
Almost Always

Poor sleep makes me forget things more easily

Rarely
Sometimes
Often
Almost Always

Poor sleep makes it hard to concentrate at work

Rarely
Sometimes
Often
Almost Always

I have difficulty getting out of bed

Rarely
Sometimes
Often
Almost Always

Poor sleep makes me easily tired at work

Rarely
Sometimes
Often
Almost Always

I have a clear head after sleep

Rarely
Sometimes
Often
Almost Always

Poor sleep makes my life painful

Rarely
Sometimes
Often
Almost Always

In general, how would you describe the effectiveness of the therapy?

What did you like most about the therapy?

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