Part I.

Perceived Stress Scale (PSS-10)

Questions Never Almost Sometimes Fairly Very

Never Often often

1. In the last month, how

often have you been upset
because of something that
happened unexpectedly?

2. In the last month, how

often have you felt unable
to control the important
things in your life?

3. In the last month, how

often have you felt
nervous and “stressed”?

4. In the last month, how

often have you felt
confident about your
ability to handle personal
problems?

5. In the last month, how

often have you felt that
things were going your
way?

6. In the last month, how

often have you found that
you could not cope with all
the things you had to do?

7. In the last month, how

often have you been able
to control irritations in your
life?

8. In the last month, how

often have you felt that
you were on top of
things?

9. In the last month, how

often have you been
angered because of things
that were outside of your
control?

10. In the last month, how

 often have you felt
difficulties were piling up
so high that you could not
overcome them?

Part II. Pittsburgh Sleep Quality Index (PSQI) – 20 Items

Instructions: The following questions ask about your usual sleep habits during the
past month. Please answer each question as accurately as possible.
Scale for frequency-based items: 0 = Not during the past month 1 = Less than
once a week 2 = Once or twice a week 3 = Three or more times a week
Section A: Sleep Patterns
1. During the past month, what time have you usually gone to bed at night?
2. During the past month, how long (in minutes) has it usually taken you to fall
asleep each night?
3. During the past month, what time have you usually gotten up in the morning?
4. During the past month, how many hours of actual sleep did you get at night?
(This may be different from the number of hours you spent in bed.)
Section B: Sleep Disturbances
5. During the past month, how often have you had trouble sleeping because you
could not get to sleep within 30 minutes?
6. During the past month, how often have you had trouble sleeping because you
woke up in the middle of the night or early morning?
7. During the past month, how often have you had trouble sleeping because you
had to get up to use the bathroom?
8. During the past month, how often have you had trouble sleeping because you
could not breathe comfortably?
9. During the past month, how often have you had trouble sleeping because you
coughed or snored loudly?
10. During the past month, how often have you had trouble sleeping because you
felt too cold?
11. During the past month, how often have you had trouble sleeping because you
felt too hot?
12. During the past month, how often have you had trouble sleeping because you
had bad dreams?
13. During the past month, how often have you had trouble sleeping because you
had pain?
Section C: Sleep Medication & Daytime Functioning
14. During the past month, how often have you taken medicine (prescribed or
“over the counter”) to help you sleep?
15. During the past month, how often have you had trouble staying awake while
driving, eating meals, or engaging in social activity?
16. During the past month, how much of a problem has it been for you to keep up
enthusiasm to get things done?
Section D: Overall Sleep Quality
17. During the past month, how would you rate your overall sleep quality? (Very
good, Fairly good, Fairly bad, Very bad)
Section E: Bed Partner / Roommate Report (if applicable)
18. Does your bed partner or roommate report that you snore loudly?
19. Does your bed partner or roommate report that you have long pauses
between breaths while asleep?
20. Does your bed partner or roommate report that you have episodes of
disorientation or confusion during sleep, or other restlessness?
🧾 Scoring and Interpretation
 Each component (sleep latency, duration, disturbances, medication use,
daytime dysfunction, and overall quality) is scored from 0 to 3.
 The global PSQI score is the sum of all component scores.
 Interpretation:
o 0–5: Good sleep quality
o >5: Poor sleep quality

Section A: Sleep Patterns

1. During the past month, what time have you usually
gone to bed at night?
2. During the past month, how long (in minutes) has it
usually takes you to fall asleep each night?
3. During the past month, what time have you usually
gotten up in the morning?
4. During the past month, how many hours of actual sleep
did you get at night?
Section B. Sleep Disturbances
Not Less Once or Three or
during than twice a more
the past once a week (2) times a
month (0) week (1) week (3)
5. During the past month, how
often have you had trouble
sleeping because you could not
get to sleep within 30 minutes?
6. During the past month, how
often have you had trouble
sleeping because you woke up
in the middle of the night or
early morning?
7. During the past month, how
often have you had trouble
sleeping because you had to get
up to use the bathroom?
8. During the past month, how
often have you had trouble
sleeping because you could not
breathe comfortably?
9. During the past month, how
often have you had trouble
sleeping because you coughed
or snored loudly?
10. During the past month, how
often have you had trouble
sleeping because you felt too
cold?
11. During the past month, how
often have you had trouble
sleeping because you felt too
hot?
12. During the past month, how
often have you had trouble
sleeping because you had bad
 dreams?
13. During the past month, how
often have you had trouble
sleeping because you had pain?

Not Less Once Three

during than or or more
the once a twice times a
past week a week
month (1) week (3)
(0) (2)
14 During the past month, how often have
. you taken medicine (prescribed or “over
the counter”) to help you sleep?
15 During the past month, how often have
. you had trouble staying awake while
driving, eating meals, or engaging in
social activity?
16 During the past month, how much of a
. problem has it been for you to keep up
enthusiasm to get things done?
Section C: Sleep Medication & Daytime Functioning