Template Patient Information Insomnia Questionnaire Template

Insomnia Questionnaire Template

Insomnia Questionnaire Template

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19
Questions
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Insomnia Questionnaire Template

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1.
What is your gender?
Female
Male
Non-binary
Prefer not to answer
2.
What is your age range?
16-26
27-37
38-48
49-59
60+
3.
What is your marital status?
Single
Married
Divorced
Widowed
Prefer not to answer
4.
What is your employment status?
Employed full-time
Employed part-time
Self-employed
Unemployed
Not looking for a job
Student
Prefer not to answer
5.
How often has poor sleep troubled you in the last month?
Never
Always
6.
How often have you been unable to sleep in the last month?
Never
Always
7.
How many nights per week do you think you have poor sleep?
8.
How often do you feel sleepy during the day while working?
Never
Always
9.
For how long have you been experiencing sleep problems?
Less than a month
1-3 months
4-6 months
6-9 months
10-12 months
More than a year
10.
Would you describe yourself as a morning person?
Yes
No
Neither
11.
Do you work night shifts?
Yes
No
12.
How many hours of sleep do you get in a 24-hour period?
13.
Who do you usually sleep with?[Checkboxes]
Alone
With partner
With roommates
With parents
With children
14.
Do you smoke?
Yes
No
15.
Do you usually drink alcohol?
Yes
No
16.
Do you typically drink coffee?
Yes
No
17.
How often do you exercise each week?
I don’t exercise at all
Once a week
2-3 times a week
4-5 times a week
5-6 times a week
Every day
18.
How often do you feel depressed?
Never
Always
19.
Please indicate any additional comments
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Template instructions
Insomnia questionnaire template helps healthcare providers assess patients' sleep quality and identify insomnia symptoms. Use this form in clinics, telehealth visits, or sleep studies to gather standardized patient-reported sleep data.

The template includes demographic and lifestyle questions (gender, age range, marital and employment status), frequency and duration of sleep problems, daytime sleepiness, night shift work, sleep partners, sleep hours, and substance use such as smoking, alcohol, and caffeine.

It also contains items about exercise frequency, depressive feelings, and an open comment field for additional notes. Scenarios include primary care screening, sleep clinic intake, research studies, and remote monitoring. Responses can be exported to electronic records or integrated with apps for tracking and follow-up for improved patient outcomes.

Click "Use This Template" to customize, embed, or share this free template and start collecting sleep assessments from your patients today.

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