Insomnia Severity Index

Patient First Name

Patient Middle Name

Patient Last Name

Date

For each question, please check the box to the number that best describes your answer. Please rate the CURRENT (i.e. LAST 2 WEEKS) SEVERITY of your insomnia problem(s).

1. Difficulty falling asleep

2. Difficulty staying asleep

3. Problems waking up too early

4. How SATISFIED/DISSATISFIED are you with your CURRENT sleep pattern?

5. How NOTICEABLE to others do you think your sleep problem is in terms of impairing the quality of your life?

6. How WORRIED/DISTRESSED are you about your current sleep problem?

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

Patient/Client First Name

Patient/Client Last Name

Patient/Client Signature

Date