Insomnia Severity Index

Patient Details

Title *

First Name *

Last Name *

Date of Birth *

Gender *

Contact Number *Please include the area code if you are inputting a home phone number.

Insomnia Severity Questionnaire

Please answer the following questions to the best of your ability. For each question, please mark the number that best describes your experience over the past two weeks.

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

2. How often have you had trouble falling asleep? *

3. How often have you had trouble staying asleep (waking up too early or waking up in the middle of the night)? *

4. How often have you had trouble waking up too early and not being able to fall asleep again? *

5. How often have you felt rested when you woke up in the morning? *

6. How often have you had trouble staying awake while driving, eating meals, or engaging in social activity? *

Total Score

Final Score *Calculate your score by reviewing the number next to each answer you checked and total it below.

Remember that this is a self-report questionnaire, and it's important to consult a healthcare professional for a comprehensive evaluation if you have concerns about your sleep or insomnia to be assessed in conjunction with your medical history by a qualified health care provider. Thank you for submitting your answers, our MiDispensary practitioners will be in touch to discuss your answers with you in the next appointment.

I declare all answers provided herein are true and accurate to the best of my knowledge and belief.

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