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    Development of Cross-Cutting Assessment Instruments

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    agustinemmamarymay
    This document is a sleep disturbance questionnaire for adults. It contains 8 questions about sleep quality and problems over the past 7 days. The questions ask about sleep restlessness, satisfaction, refreshment, difficulty falling asleep, trouble staying asleep, sleep problems, getting enough sleep, and overall sleep quality. Respondents rate each question on a scale from 1 to 5 indicating how often they experienced the problem, with higher numbers indicating better sleep quality. The total raw score is calculated and converted to a t-score for clinical use.

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    Development of Cross-Cutting Assessment Instruments

    Uploaded by

    agustinemmamarymay
    13 views1 page
    This document is a sleep disturbance questionnaire for adults. It contains 8 questions about sleep quality and problems over the past 7 days. The questions ask about sleep restlessness, satisfaction, refreshment, difficulty falling asleep, trouble staying asleep, sleep problems, getting enough sleep, and overall sleep quality. Respondents rate each question on a scale from 1 to 5 indicating how often they experienced the problem, with higher numbers indicating better sleep quality. The total raw score is calculated and converted to a t-score for clinical use.

    Original Description:

    DSM 5 screening MHS

    Original Title

    Development of Cross-cutting Assessment Instruments

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    This document is a sleep disturbance questionnaire for adults. It contains 8 questions about sleep quality and problems over the past 7 days. The questions ask about sleep restlessness, satisfaction, refreshment, difficulty falling asleep, trouble staying asleep, sleep problems, getting enough sleep, and overall sleep quality. Respondents rate each question on a scale from 1 to 5 indicating how often they experienced the problem, with higher numbers indicating better sleep quality. The total raw score is calculated and converted to a t-score for clinical use.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    13 views1 page

    Development of Cross-Cutting Assessment Instruments

    Uploaded by

    agustinemmamarymay
    This document is a sleep disturbance questionnaire for adults. It contains 8 questions about sleep quality and problems over the past 7 days. The questions ask about sleep restlessness, satisfaction, refreshment, difficulty falling asleep, trouble staying asleep, sleep problems, getting enough sleep, and overall sleep quality. Respondents rate each question on a scale from 1 to 5 indicating how often they experienced the problem, with higher numbers indicating better sleep quality. The total raw score is calculated and converted to a t-score for clinical use.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    of 1

    LEVEL 2—Sleep Disturbance—Adult*

    *PROMIS—Sleep Disturbance—Short Form

    Name: ________________________________ Age: ____ Sex:  Male  Female Date:________________

    If the measure is being completed by an informant, what is your relationship with the individual receiving care? __________________

    In a typical week, approximately how much time do you spend with the individual receiving care? __________________ hours/week

    Instructions to patient: On the DSM-5 Level 1 cross-cutting questionnaire that you just completed, you indicated that during the past
    2 weeks you (the individual receiving care) have been bothered by “problems with sleep that affected your sleep quality over all” at a
    mild or greater level of severity. The questions below ask about these feelings in more detail and especially how often you (the
    individual receiving care) have been bothered by a list of symptoms during the past 7 days. Please respond to each item by marking
    ( or x) one box per row.

    Clinician
    Use
    In the past SEVEN (7) DAYS....
    Not at all A little bit Somewhat Quite a bit Very much
    1. My sleep was restless.  1 2 3 4 5

    2. I was satisfied with my sleep.  5 4 3 2 1

    3. My sleep was refreshing.  5 4 3 2 1

    4. I had difficulty falling asleep.  1 2 3 4 5

    In the past SEVEN (7) DAYS....


    Never Rarely Sometimes Often Always
    5. I had trouble staying asleep.  1 2 3 4 5

    6. I had trouble sleeping.  1 2 3 4 5

    7. I got enough sleep.  5 4 3 2 1

    In the past SEVEN (7) DAYS....


    Very Poor Poor Fair Good Very good
    8. My sleep quality was...  5 4 3 2 1
    Total/Partial Raw Score:
    Prorated Total Raw Score:
    T-Score:
    ©2008-2012 PROMIS Health Organization (PHO) and PROMIS Cooperative Group.
    This material can be reproduced without permission by clinicians for use with their patients.
    Any other use, including electronic use, requires written permission of the PHO.

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