| RPT |
.| .| Insomnia Severity Index| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| SSN: <.Patient_SSN.>| DOB:
<.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | ISI score: <-ISI->| | Score categories:| 0 - 7 No clinically significant insomnia| 8 - 14 Subthreshold
insomnia| 15 - 21 Clinical insomnia (moderate severity)| 22 - 28 Clinical insomnia (severe)| | Questions and Answers| | 1. Difficulty falling asleep.| <*Answer_6632*>| 2. Difficulty
staying asleep.| <*Answer_6633*>| 3. Problems waking up too early.| <*Answer_6634*>| 4. How SATISFIED/DISSATISFIED are you with your CURRENT sleep pattern?| <*Answer_6635*>| 5. How
NOTICEABLE to others do you think your sleep problem is in terms of impairing the quality of your life?| <*Answer_6636*>| 6. How WORRIED/DISTRESSED are you about your current sleep problem?|
<*Answer_6637*>| 7. To what extent do you consider your sleep problem to INTERFERE with your daily functioning (e.g. daytime fatigue, mood, ability to function at work/daily chores, concentration,
memory, mood, etc.) CURRENTLY? | <*Answer_6638*>| | | Information contained in this note is based on a self-report assessment and is not sufficient to use alone for diagnostic purposes.
Assessment results should be verified for accuracy and used in conjunction with other diagnostic activities and procedures.| $~
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