Insomnia Severity Index - Welcome to My Practice

Insomnia Assessment

Date*
MM slash DD slash YYYY
Name*
First Last
Please rate the current (last two weeks) severity of your insomnia problem 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?
5. How noticable to others do you think your sleep problem is in terms of impairing the quality of your life?
6. How worried /distressed are you about your current sleep problem?
7. To what extent do you consider your sleep problem to interfere with your daily functioning (i.e. daytime fatigue, mood, ability to function at work/daily chores, concentration, memory, mood, etc.) CURRENTLY?

Guidelines for Scoring/Interpretation:
Add the scores for all seven items (questions 1 + 2 + 3 + 4 + 5 +6 + 7) = _______ your total 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)

Used via courtesy of www.myhealth.va.gov with permission from Charles M. Morin, Ph.D., Université Laval