Questionnaire Sleepweek

Enter your SleepCode (SlaapCode) *

What practice enrolled you for the Sleepweek? *

For each of the following 32 statements, please indicate to what extent they are applicable to you.

Check one of these response options:

1 = not at all applicable
2 = usually not applicable
3 = applicable at times
4 = usually applicable
5 = applicable

• Don’t skip any questions.

• In responding to these questions, consider the past three months.

• Even though you might not know this about yourself (for example whether you snore or move your legs), indicate what you have heard from your partner or what you believe to be true.

1. During the day, I suffer from fatigue. *

2. When I lie down in bed, I experience unpleasant, itchy, or burning sensations in my legs. *

3. I wake up with a dry mouth in the morning. *

4. I wake up in the middle of the night, screaming and/or heavily perspiring and feeling anxious. *

5. I don’t fall asleep until the morning and have great difficulty waking up early. I sleep in on weekends. *

6. When I experience ‘restless legs’, I can suppress these sensations by walking or stretching my legs. *

7. The quality of my sleep is poor and I don’t feel well rested in the morning. *

8. When I am sitting still, especially in the evenings, I feel an urge to move my legs. *

9. I move my arms or legs during sleep. *

10. At night, I lie awake for a long time. *

11. While asleep I suffer from kicking leg movements that I just cannot suppress. *

12. I worry about the consequences of my poor sleep (e.g. for my health). *

13. I have difficulty falling asleep at night. *

14. Especially after a bad night, I suffer from one or more of the following consequences: fatigue, sleepiness, bad mood, poor concentration, memory problems, and lack of energy. *

15. Despite having plenty of opportunity to sleep in, I don’t get enough sleep. *

16. I regularly have vivid dreams in which I am being attacked and try to defend myself with uncontrolled movements. *

17. I stop breathing during sleep. *

18. I snore loudly while I am asleep. *

19. At night I wake up with a start feeling like I am choking. *

20. I suffer from nightmares or bad dreams. *

21. Because of insufficient sleep, I don’t function as well during the day. *

22. I have injured myself during sleep and had no recollection of the event afterwards. *

23. I fall asleep repeatedly throughout the day. *

24. Quite often I partially wake up and find myself thrashing my arms. I usually don’t recall this later on. *

25. After a daytime nap I don’t feel refreshed. *

26. I sleep poorly because I don’t manage to fall asleep at a normal hour and wake up at a normal hour in the morning. *

27. When I have to stay awake during the night, my daytime sleep is poor. *

28. I usually sleep more than 10 hours a night, have difficulty waking up in the morning, and nap during the day. *

29. During the day, I suffer from sleep attacks that are so severe that I cannot suppress them. *

30. The time at which I fall asleep varies strongly from day to day. *

31. I suffer from sleepwalking. *

32. During the day, I fall asleep involuntarily, especially in monotonous situations (e.g. during a boring TV show). *

Insomnia Severity Index

The questions below address the way you experience your sleep.

For each question, please CHECK the number that best describes your answer.

Please rate the CURRENT (i.e. LAST 2 WEEKS) SEVERITY of your insomnia problem(s).

Difficulty falling asleep (0 = None, 1= Mild, 2 = Moderate, 3 = Severe, 4 = Very Severe) *

Difficulty staying asleep (0 = None, 1= Mild, 2 = Moderate, 3 = Severe, 4 = Very Severe) *

Problems waking up too early (0 = None, 1= Mild, 2 = Moderate, 3 = Severe, 4 = Very Severe) *

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

0 = Very Satisfied, 1 = Satisfied, 2 = Moderately Satisfied, 3 = Dissatisfied, 4 = Very Dissatisfied *

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?

0 = Not at all Interfering, 1 = A Little, 2 = Somewhat, 3 = Much, 4 = Very Much Interfering *

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

0 = Not at all Noticeable, 1 = A Little, 2 = Somewhat, 3 = Much, 4 = Very Much Noticeable *

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

0 = Not at all Worried, 1 = A Little, 2 = Somewhat, 3 = Much, 4 = Very Much Worried *

Extra questions on 'restless legs'

How often do you suffer from 'restless legs' in a week? *

1 - 2 days

3 - 5 days

6 - 7 days

What time does it usually start? *

Only at bedtime

After 6 PM

After 12 AM

Scoring HSDQ

Er is sprake van een algemene slaapstoornis indien de criterium-waarde van 2.02 wordt overschreden.

Pas indien de criterium-waarde voor een algemene slaapstoornis wordt overschreden, kan getoetst worden voor de aanwezigheid van één of meer specifieke slaapstoornis(-sen). Bepaal voor iedere specifieke slaapstoornis of de criterium-waarde voor die schaal wordt overschreden.

Schalen (items)

Criterium

Insomnia, slapeloosheid (1, 7, 10, 12, 13, 14, 15, 21)

3.68

Parasomnia, bijv. slaapwandelen (4, 16, 20, 22, 24, 31)

2.42

CRSD, bijv. vertraagde slaapfasestoornis (5, 10, 13, 26, 27, 30)

3.41

Hypersomnolentie, bijv. narcolepsie (23, 25, 28, 29, 32)

2.90

RLS-LMS, bijv. restless legs syndrome (2, 6, 8, 9, 11)

2.70

SBD, bijv. slaap-apneu syndroom (3, 17, 18, 19)

2.87

Scoring ISI

0 - 7	Geen klinisch significante insomnia
8 - 14	Subklinische insomnia
15 - 21	Klinisch significante insomnia (matig ernstig)
22 - 28	Klinisch significante insomnia (ernstig)

Insomnia Severity Index (ISI)

* = Input is required