Clinical Screening

Insomnia Severity Index (ISI)

Rate the CURRENT (last 2 weeks) severity of your insomnia problems. Select the number that best describes your answer. 0 = none, 4 = very severe.

Patient Information

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Last Name *

Date of Birth *

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? (Very Satisfied = 0 … Very Dissatisfied = 4)

5. How NOTICEABLE to others do you think your sleep problem is in terms of impairing the quality of your life? (Not at all = 0 … Very Much = 4)

6. How WORRIED/DISTRESSED are you about your current sleep problem? (Not at all = 0 … Very Much = 4)

7. To what extent do you consider your sleep problem to INTERFERE with your daily functioning (daytime fatigue, mood, ability to function at work/daily chores, concentration, memory, etc.) CURRENTLY? (Not at all = 0 … Very Much = 4)

Total Score: 0/28

No clinically significant insomnia

Patient Signature

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Date *