Patient code (example: K12345) - you have received this from us *.

Data protection is very important to us, therefore medical and personal data is only sent in encrypted form. For additional protection, we ask you not to enter any data that can be traced back to you. The patient code allows us to assign the sent data to your file.

The following questions refer to your usual sleeping habits and only during the last four weeks. Your answers should be as accurate as possible and refer to the majority of the days and nights during the last four weeks. Please answer all of the questions. For each of the following questions, please mark the answer that applies to you.

1. what time did you usually go to bed at night during the last four weeks? *

24h format (example 22:30)

2. during the last four weeks, how long did it usually take you to fall asleep at night? (in minutes) *

Example: 15

3. what time did you usually get up in the morning during the last four weeks? *

24h format (example: 07:30)

4. how many hours did you actually sleep per night during the last four weeks? *

This does not have to be the same as the number of hours you have spent in bed.

For each of the following questions, please mark the answer that applies to you. Please answer all questions.

5. during the last four weeks, how often did you sleep poorly, ...

a) ... because you could not fall asleep within 30 minutes? *

During the last four weeks not at all
Less than once a week
Once or twice a week
Three times or more per week

b) ... because you woke up in the middle of the night or early in the morning? *

During the last four weeks not at all
Less than once a week
Once or twice a week
Three times or more per week

c) ... because you had to get up to go to the bathroom? *

During the last four weeks not at all
Less than once a week
Once or twice a week
Three times or more per week

d) ... because you had trouble breathing? *

During the last four weeks not at all
Less than once a week
Once or twice a week
Three times or more per week

e) ... because you had to cough or snored loudly? *

During the last four weeks not at all
Less than once a week
Once or twice a week
Three times or more per week

f) ... because you were too cold? *

During the last four weeks not at all
Less than once a week
Once or twice a week
Three times or more per week

g) ... because you were too warm? *

During the last four weeks not at all
Less than once a week
Once or twice a week
Three times or more per week

h) ... because you had a bad dream? *

During the last four weeks not at all
Less than once a week
Once or twice a week
Three times or more per week

i) ... because you were in pain? *

During the last four weeks not at all
Less than once a week
Once or twice a week
Three times or more per week

j) ... for other reasons? *

During the last four weeks not at all
Less than once a week
Once or twice a week
Three times or more per week

6. overall, how would you rate the quality of your sleep during the past four weeks? *

Very good
Pretty good
Pretty bad
Very bad

7. during the past four weeks, how often did you take sleeping pills (prescribed by a doctor or over-the-counter)? *

During the last four weeks not at all
Less than once a week
Once or twice a week
Three times or more per week

8. during the past four weeks, how often did you have difficulty staying awake, such as while driving, eating, or attending social events? *

During the last four weeks not at all
Less than once a week
Once or twice a week
Three times or more per week

9. during the last four weeks, did you have problems doing the usual everyday tasks with enough drive? *

No problems
Hardly any problems
Some problems
Big problems

10. do you sleep alone in your room? *

Yes
Yes, but a partner/roommate sleeps in another room
No, the partner sleeps in the same room, but not in the same bed
No, the partner sleeps in the same bed

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PSQI - Test

Attention: This PSQI test is only for our patients, for anamnesis. This test does not provide immediate results. Here you can find a PSQI test with immediate evaluation

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