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Physician Referral Forms
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.
1. Do you have difficulty falling asleep? (0-None, 1-Mild, 2-Moderate, 3-Severe, 4-Very Severe) 01234
2. Do you have difficulty staying asleep? (0-None, 1-Mild, 2-Moderate, 3-Severe, 4-Very Severe) 01234
3. Do you have problems waking up too early? (0-None, 1-Mild, 2-Moderate, 3-Severe, 4-Very Severe) 01234
4. How SATISFIED/DISSATISFIED are you with your CURRENT sleep pattern? (0-Very Satisfied, 1-Satisfied, 2-Moderately Satisfied, 3-Dissatisfied, 4-Very Dissatisfied) 01234
5. 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) 01234
6. 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) 01234
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? (0-Not At All Interfering, 1-A Little, 2-Somewhat, 3-Much, 4-Very Much Interfering) 01234
Your Score:
Total score categories: 0–7 = No clinically significant insomnia 8–14 = Subthreshold insomnia 15–21 = Clinical insomnia (moderate severity) 22–28 = Clinical insomnia (severe)
Would you like us to contact you regarding your results? YesNo
Your Name
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604-558-0055
Take The Sleep Apnea Self-Test
Physician Referral Forms