INSOMNIA SEVERITY INDEX

Instructions:

The Insomnia Severity Index has seven questions. The seven answers are added up to get a total score. When you have your total score, look at the "Guidelines for Scoring/Interpretation" below to see where your sleep difficulty fits.

For each question, please check the box next to the number that best describes your answer. Please rate the current (i.e. last two weeks) severity of your insomnia problem(s)

How satisfied/dissatisfied are you with your current sleep pattern?

Patient Demographics

Patient Name

Contact number *

Email *

Gender

Male

Female

Date of birth

I agree to Sleep Medicine Specialists of California’s terms & conditions

Signature of Patient, Parent or Legal Guardian *

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