* Required

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? *