Next to each question assign a number between 0 and 5. You should assign values as follows:
Once you have completed the questionnaire calculate your total and locate the range you fall under on page two.
| 1. I experience problems falling asleep. |
0 |
1 |
2 |
3 |
4 |
5 |
| 2. I experience problems staying asleep. |
0 |
1 |
2 |
3 |
4 |
5 |
| 3. I frequently experience a second wind (high energy) late at night. |
0 |
1 |
2 |
3 |
4 |
5 |
| 4. I have energy highs and lows throughout the day. |
0 |
1 |
2 |
3 |
4 |
5 |
| 5. I feel tired all the time. |
0 |
1 |
2 |
3 |
4 |
5 |
| 6. I need caffeine (coffee, tea, cola, etc) to get going in the morning. |
0 |
1 |
2 |
3 |
4 |
5 |
| 7. I usually go to bed after 10 pm. |
0 |
1 |
2 |
3 |
4 |
5 |
| 8. I frequently get less than 8 hours of sleep per night. |
0 |
1 |
2 |
3 |
4 |
5 |
| 9. I am easily fatigued. |
0 |
1 |
2 |
3 |
4 |
5 |
| 10. Things I used to enjoy seem like a chore lately. |
0 |
1 |
2 |
3 |
4 |
5 |
| 11. My sex drive is lower than it used to be. |
0 |
1 |
2 |
3 |
4 |
5 |
| 12. I suffer from depression, or have recently been experiencing feelings of depression such as sadness, or loss of motivation. |
0 |
1 |
2 |
3 |
4 |
5 |
| 13. If I skip meals I feel low energy or foggy and disoriented. |
0 |
1 |
2 |
3 |
4 |
5 |
| 14. My ability to handle stress has decreased. |
0 |
1 |
2 |
3 |
4 |
5 |
| 15. I find that I am easily irritated or upset. |
0 |
1 |
2 |
3 |
4 |
5 |
| 16. I have had one or more stressful major life events. (ie: divorce, death of a loved one, job loss, new baby, new job) |
0 |
1 |
2 |
3 |
4 |
5 |
| 17. I tend to overwork with little time for play or relaxation for extended periods of time. |
0 |
1 |
2 |
3 |
4 |
5 |
| 18. I crave sweets. |
0 |
1 |
2 |
3 |
4 |
5 |
| 19. I frequently skip meals or eat sporadically. |
0 |
1 |
2 |
3 |
4 |
5 |
| 20. I am experiencing increased physical complaints such as muscle aches, headaches, or more frequent illnesses. |
0 |
1 |
2 |
3 |
4 |
5 |