We are interested in knowing about your sleep experience while in the hospital.

Please take
a few minutes to answer the following questions. Thank you for your time.

During the past month, how would you rate your sleep quality overall?
Very good ___________
Fairly good ___________
Fairly bad ___________
Very bad ___________

During the past month, how much of the time have you been anxious or worried?
(Circle One)
All of the time................................................................1
Most of the time.............................................................2
A good bit of the time....................................................3
Some of the time ............................................................4
A little of the time..........................................................5
None of the time ............................................................6

How did you feel upon arising this morning? Please circle your response.

1 2 3 4 5
Exhausted Tired Average Rather refreshed Very refreshed

How was your sleep quality last night? Please circle your response.

1 2 3 4 5
Very restless Restless Average quality Sound Very sound.


If you did not get rest last night, what kept you awake?
________________________________________________________________________

On this scale, please indicate the average pain you had in the past 24 hours.
0 1 2 3 4 5 6 7 8 9 10
No pain Worst pain possible


Please indicate if last night you heard the following sounds that may have interfered with
your sleep. Place a check mark in the box that indicates what you heard.

Not at all Somewhat Moderately Quite a bit Extremely
Patient
sounds such
as coughing,
gagging,
moaning

Talking in
the hallway

Doors
opening,
closing,
slamming

Falling
objects such
as pans,
patient charts

Nurses
socializing at
the nurses
station

Squeaking
parts on beds
and
equipment



Is there anything we can do to help you sleep better or get some rest while in the hospital?

___________________________________________________________________________