Questionaire_sleep.pdf

Questionnaire for sleep.sav
{Please note: I have included below selected items from a more extensive questionnaire used in a
study on the impact of sleep problems. Two additional scales were included (Epworth Sleepiness Scale,
Hospital Anxiety and Depression Scale) however these items are not displayed in the questionnaire for
copyright reasons. The total scores however do appear as variables in the datafile.}
‰ primary school ‰ secondary school ‰ trade training/ post secondary training ‰ undergraduate degree ‰ postgraduate degree general health very poor 1 2 3 4 5 6 7 8 9 10 very good physical fitness very poor 1 2 3 4 5 6 7 8 9 10 very good current weight very underweight 1 2 3 4 5 6 7 8 9 10 very overweight Do you smoke? ‰ Yes ‰ No : If yes, how many cigarettes do you smoke per day? ___________ How many standard alcoholic drinks do you consume on an average day? ___________ How many drinks containing caffeine (eg. coffee, tea or cola) do you drink per day? _________ General y, how many hours sleep do you get: On weeknights: _____hours On weekends: _____hours How many hours sleep do you think you need so that you don’t feel sleepy the next day? __________ hours Do you have trouble fal ing asleep? ‰ Yes ‰ No Do you have trouble staying asleep? ‰ Yes ‰ No Are you aware of waking up during the night? Do you work night shift or rotating shifts? Would you describe yourself as a ‘light sleeper’ (easily awoken) ‰ Yes ‰ No Do you usual y wake up feeling refreshed? On weekdays? ‰ Yes ‰ No How satisfied are you with the amount of sleep you get? very dissatisfied 1 2 3 4 5 6 7 8 9 10 very satisfied Overal how would you rate the quality of your sleep? ‰ very poor ‰ poor ‰ fair ‰ good ‰ very good ‰ excel ent Please rate how stressed you have felt over the last month: not at al 1 2 3 4 5 6 7 8 9 10 extremely stressed Do you regularly take any medication to help you sleep? Do you feel you have a problem of any sort with your sleep? ‰ No Please skip to the next section ‰ Yes Please answer the questions below: To what extent do you feel that the fol owing aspects of your life are affected by your problem with sleep? (please circle a number on each line below) not at al 1 2 3 4 5 6 7 8 9 10 to a great extent not at al 1 2 3 4 5 6 7 8 9 10 to a great extent not at al 1 2 3 4 5 6 7 8 9 10 to a great extent not at al 1 2 3 4 5 6 7 8 9 10 to a great extent not at al 1 2 3 4 5 6 7 8 9 10 to a great extent not at al 1 2 3 4 5 6 7 8 9 10 to a great extent not at al 1 2 3 4 5 6 7 8 9 10 to a great extent Has your partner/ family member ever said you stop breathing at times during your sleep? Are you a ‘restless sleeper’? ‰ Yes ‰ No Have you ever fal en asleep while driving? ‰ Yes ‰ No {Note. The items shown below were distributed at different points throughout the original version of the ful questionnaire, but are shown as a block here as they al form part of the Sleepiness and Associated Sensations Scale} Please rate how fatigued you’ve felt over the past month: not at al 1 2 3 4 5 6 7 8 9 10 to a great extent Please rate how lethargic you have felt over the past month: not at al 1 2 3 4 5 6 7 8 9 10 to a great extent Please rate how tired you’ve felt over the past month: not at al 1 2 3 4 5 6 7 8 9 10 to a great extent Please rate how sleepy you’ve felt over the past month: not at al 1 2 3 4 5 6 7 8 9 10 to a great extent Please rate how much you’ve felt lacking in energy over the past month: not at al 1 2 3 4 5 6 7 8 9 10 to a great extent Codebook for sleep.sav
Coding instructions
Variable
Description of variable
Rate impact of sleep problem on memory impact4 Rate impact of sleep problem on life sat

Source: http://www.paolocoletti.it/advancedcomputer/exercisesC/sleep_questionaire.pdf

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