Protocol - Sleep Disorders Screener

Date: ___________________________________

Interviewer: ______________________________

Co-raters: ________________________________

Duration: _________________________________

I am now going to ask you about your usual sleep patterns.

INTERVIEWER: Please tell participant that they should not reveal their diagnosis to you.

Routine Sleep Schedule

No

Yes

Unk

DASLP999

Do you normally work (or attend school) during the day and sleep at night?

INTERVIEWER: If individual is unemployed and out of school, ask about his/her usual time of activity instead.

0

1

9

Code Response

DASLP999

What is your normal work (or school) and sleep schedule?

1

2

3

1 = Always works nights, sleeps during the day

2 = Schedule rotates/Shift Work

3 = Other, Describe:

___________________________________________

___________________________________________

___________________________________________

DASLP999

(If response = 2)

What shift schedule do you most often work?

1 = Day Shift (approx. 7am- 3pm)

2 = Evening Shift (approx. 3pm- 11pm)

3 = Night Shift (approx. 11pm- 7am)

4 = Other:

1

2

3

4

Use the one shift schedule selected for the following questions regarding your workdays.

At what time do you usually go to bed:

Time

DASLP999

On a workday or school day?

____: ___

□ AM □ PM

DASLP999

On a non-work or non-school day (i.e., weekend)?

____: ___

□ AM □ PM

About how many minutes does it usually take for you to fall asleep:

Minutes

DASLP999

On a workday or school day?

DASLP999

On a non-work or non-school day (i.e., weekend)?

At what time do you usually wake up:

Time

DASLP999

On a workday or school day?

______ : ______

□ AM □ PM

DASLP999

On a non-work or non-school day (i.e., weekend)?

______ : ______

□ AM □ PM

Minutes

Hours

DASLP999

How long does it take for you to become fully awake from regular sleep (i.e., after first opening your eyes in the morning)?

Never

Sometimes

Always

DASLP999

Do you use an alarm clock to wake up in the morning?

0

1

2

DASLP999

Do you have great difficulty waking up in the morning?

0

1

2

DASLP999

Do you often have so much trouble waking up that an alarm clock wont wake you and you have to use other methods to wake up?

Describe: ___________________________________________

___________________________________________

___________________________________________

0

1

2

DASLP999

When you wake up in the morning or from a nap, do you feel "out of it" and confused?

0

1

2

Hours

Minutes

DASLP999

How long does it take for you to fully awaken?

How much sleep do you usually get during a typical night:

Hours

Minutes

DASLP999-DASLP999

On a workday or school day?

DASLP999-DASLP999

On a non-work or non-school day (i.e., weekend)?

No

Yes

Unk

DASLP999

Do you usually follow the same sleep schedule (i.e., no more than a 1 hour difference in sleep and wake times) on both work/school and non-work/school days? (or school days and weekends)

0

1

9

Hours

DASLP999

How many hours of sleep per night do you think you need to feel fully rested the next day?

Never

Sometimes

Always

DASLP999

Do you feel awake and refreshed after sleeping?

0

1

2

Code Response

DASLP999

How often do you remember your dreams? That is, dreams that occur during your regular sleep and not while napping.

0

1

2

3

4

9

0 = Never

1 = Rarely (once a month or less)

2 = Sometimes (2-4 times per month)

3 = Often (5-15 times per month)

4 = Almost always (16-30 times per month)

9 = Dont Know

Naps

Code Response

DASLP999

How often do you take naps?

0

1

2

3

4

9

0 = Never

1 = Rarely (once a month or less)

2 = Sometimes (2-4 times per month)

3 = Often (5- 15 times per month)

4 = Almost Always (16-30 times per month)

9 = Dont know

If respondent never naps, SKIP to Sleep Deprivation.

Time

DASLP999

At what time(s) of the day do you usually take naps?

INTERVIEWER: List up to 3 time(s) of the day.

______ : ______

□ AM □ PM

DASLP999

______ : ______

□ AM □ PM

DASLP999

______ : ______

□ AM □ PM

Hours

Minutes

DASLP999-DASLP999

How many hours and minutes of sleep do you usually get when you take a nap?

Never

Sometimes

Always

DASLP999

Do you have great difficulty waking up from naps?

0

1

2

Code Response

DASLP999

How often do you dream when you nap?

0

1

2

3

4

9

0 = Never

1 = Rarely (once a month or less)

2 = Sometimes (2-4 times per month)

3 = Often (5-15 times per month)

4 = Almost always (16-30 times per month)

9 = Dont Know

No

Yes

Unk

DASLP999

Are these dreams very intense, detailed and vivid, like watching a movie?

0

1

9

Sleep Deprivation

Code Response

DASLP999

How difficult is it for you to adapt to a sleep loss of 3 hours or more (i.e. sleeping 3 or more hours less than you normally do the night before)?

0

1

2

3

9

0 = Not at all difficult

1 = Not very difficult

2 = Somewhat difficult

3 = Very difficult

9 = Dont know

INTERVIEWER: For the questions below, first determine whether sleep loss affects these factors. If there is a change following sleep loss, circle whether there is an improvement or a worsening, or an increase or decrease.

Does this loss of sleep affect you the next day with respect to…? (If yes, How?)

No

Yes

Circle One

DASLP999-DASLP999

…your mood (being sadder or happier)?

0

1

Improves

2

Worsens

3

Both

4

DK

9

DASLP999-DASLP999

…your tendency to be irritable?

0

1

Increases

2

Decreases

3

Both

4

DK

9

DASLP999-DASLP999

…your ability to get your work done?

0

1

Improves

2

Worsens

3

Both

4

DK

9

DASLP999-DASLP999

…how much you eat?

0

1

Increases

2

Decreases

3

Both

4

DK

9

DASLP999-DASLP999

…your desire for chocolate or sweets?

0

1

Increases

2

Decreases

3

Both

4

DK

9

Code Response

DASLP999

How quickly after this loss of sleep, do you return to your usual self if you are allowed to sleep as much as you like?

1

2

3

4

9

1 = Within 1 day or less

2 = 2 to 3 days

3 = 4 or 5 days

4 = Over 5 days

9 = Dont Know

Sleep Regularity

No

Yes

Unk

DASLP999

Do you prefer to keep a regular sleep schedule (i.e. one that does not change much from one night to the next)?

0

1

9

Code Response

DASLP999

If you do not keep your regular sleep schedule, how much do you feel "off" (i.e. not your regular self), the next day?

0

1

2

9

0 = None, Feel the Same

1 = Yes, Somewhat Off

2 = Yes, A Great Deal Off

9 = Dont Know

Jet Lag

Code Response

DASLP999

When you are traveling EAST by air and you cross over several time zones, how quickly do you return to your usual sleeping pattern?

1

2

3

4

7

9

1 = Within 1 day or less

2 = 2 to 3 days

3 = 4 or 5 days

4 = Over 5 days

7 = N/A

9 = Dont Know

DASLP999

What about when you are traveling WEST by air over several time zones?

Code same as above.

1

2

3

4

7

9

Morningness-Eveningness

Code Response

Neither

Type

Morning

Evening

DASLP999

Do you consider yourself to be a morning person ("early bird"), an evening person ("night owl"), or neither?

0

1

2

Code Response

None

Some

Strong

DASLP999

How strong is your preference?

0

1

2

DELAYED SLEEP PHASE SYNDROME

No

Yes

Unk

DASLP999

INTERVIEWER: Does respondent consistently fall asleep very late (i.e., 12 a.m. or later) at night AND characterize him/herself as a "night owl" with a "strong preference"?

0

1

9

If no, SKIP to Insomnia section

When you do not have to maintain a strict schedule (i.e. not dictated by strict work or school schedules, as while on vacation or not working):

Time

DASLP999

…at what time do you usually go to sleep (i.e. feel sleepy and ready to go to bed)?

______ : ______

□ AM □ PM

DASLP999

…at what time do you usually wake up?

______ : ______

□ AM □ PM

No

Yes

Unk

DASLP999

…are these usual sleep and wake times always about the same (i.e. each day during a week of vacation)?

0

1

9

DASLP999

…do you wake up on your own (i.e., without an alarm or other assistance)?

0

1

9

DASLP999

Have you ever tried to force yourself to fall asleep at an (earlier) time than your usual bedtime?

0

1

9

If no, SKIP to Insomnia Section.

DASLP999

When you tried to shift your sleep schedule to an earlier bedtime (at least 1 to 2 hours earlier), did you have difficulty falling asleep?

0

1

9

DASLP999

Do attempts to change your sleep/wake schedule tend to make your sleeping difficulties worse?

0

1

9

If no, SKIP to Insomnia Section.

Weeks

Months

Years

DASLP999-DASLP999

During the past year, what was the longest period of time that you had these sleeping problems on most nights?

If less than one month, SKIP to Insomnia.

EPISODES/COURSE

Onset

Age

DASLP999

How old were you when you first began going to sleep very late without being able to adjust your schedule when you tried?

DASLP999

Offset

How old were you the last time you experienced these problems?

No

Yes

Unk

DASLP999

Do you currently experience these problems?

0

1

9

DISTRESS/IMPAIRMENT

Please look at this scale from 0 to 10, where 0 means no distress/impairment and 10 means very severe problems.

Distress

Code Response

DASLP999

How much have your late bedtime and inability to adjust your schedule upset or distressed you?

Impairment

Code Response

DASLP999

Social

What number describes how much this eveningness tendency has affected your social life and/or relationships with your friends?

DASLP999

Family

What number describes how much this eveningness tendency has affected your relationships with family members?

DASLP999

School/Work

What number describes how much this eveningness tendency has affected your performance in school/work or your relationships with your co-workers, employers, teachers or classmates?

INSOMNIA (SIMPLE AND PSYCHOPHYSIOLOGIC)

Have you ever had frequent problems

No

Yes

Unk

DASLP999

1. getting to sleep at the beginning of the night…or

0

1

9

DASLP999

2. staying asleep at night…or

0

1

9

DASLP999

3. falling back to sleep after waking in the middle of the night…

...which has negatively affected how you function during the following day?

0

1

9

If no, SKIP to Narcolepsy-Cataplexy section.

In the past year, have you…?

DASLP999

…had difficulty getting to sleep?

0

1

9

DASLP999

…awakened during the night and had a hard time getting back to sleep?

0

1

9

DASLP999

…awakened too early in the morning and couldnt get back to sleep?

0

1

9

Weeks

Months

Years

DASLP999-DASLP999

What was the longest period of time you had sleeping problems (such as those described above) on most nights during the past year?

INTERVIEWER: If respondent endorses less than one month of sleeping problems, SKIP to Narcolepsy-Cataplexy section.

Do you experience any of the following during the daytime due to your difficulties falling asleep or staying asleep at night:

No

Yes

Unk

DASLP999

Attention, concentration or memory problems?

0

1

9

DASLP999

Errors or accidents at work or while driving?

0

1

9

DASLP999

Social problems or poor work/school performance?

0

1

9

DASLP999

Fatigue?

0

1

9

DASLP999

Sleepiness?

0

1

9

DASLP999

Feeling tense/muscle tension?

0

1

9

DASLP999

Headaches?

0

1

9

DASLP999

Gastrointestinal symptoms (e.g. upset stomach, nervous stomach)?

0

1

9

DASLP999

Mood changes/problems or irritability?

0

1

9

DASLP999

A lack of motivation or energy to do things (manifested as e.g. procrastination or lack of initiative)?

0

1

9

DASLP999

Concerns or worries about sleep?

0

1

9

Do you do any of the following during the night when you cannot fall asleep, do you:

DASLP999

Experience frustration, tension and/or anxiety over not being able to go to sleep?

0

1

9

DASLP999

Look at the clock frequently to see how long you have not been able to fall asleep?

0

1

9

DASLP999

When you are NOT sleeping in your usual bed (e.g. in a hotel room while on vacation, or on your couch watching television), do you still have problems initially getting to sleep, staying asleep, or falling back to sleep after waking up during the night?

0

1

9

ASSOCIATED CONDITIONS

Does your difficulty with insomnia occur at the same time as any of the following events or conditions (i.e. is the insomnia associated temporally with any of the following)?

No

Yes

Unk

DASLP999

…caffeine or other stimulant use?

0

1

9

DASLP999

…other drugs or medications?

0

1

9

Specify:__________________________________________

DASLP999

…changing schedule?

0

1

9

Specify:__________________________________________

DASLP999

…noisy or uncomfortable surroundings?

0

1

9

Specify:__________________________________________

DASLP999

…stress or major life event?

0

1

9

Specify:__________________________________________

DASLP999

…other disturbances (i.e. children, pets, etc.)?

0

1

9

Specify:__________________________________________

DASLP999

…an emotional or mental condition?

0

1

9

Specify:___________________________________

DASLP999

…other medical condition?

0

1

9

Specify:__________________________________________

DASLP999

Do you ever have trouble falling asleep or staying asleep, when there seems to be no cause or explanation for it?

0

1

9

Specify:__________________________________________

FOR WOMEN ONLY

Has your difficulty with sleeping occurred or worsened during any of the following conditions...

No

Yes

Unk

DASLP999

...pregnancy?

DASLP999

…menopause? (ask for women over 35)

DASLP999

…just before (a few days) menstruation?

DASLP999

…menstruation?

EPISODES/COURSE

Episodes

Number Episodes

DASLP999

How many separate times in your life have you had difficulty getting to sleep, staying asleep or falling back to sleep after waking up during the night (for at least one month)?

Age

DASLP999

Onset

How old were you when you first experienced this kind of difficulty with sleeping (for at least one month)?

DASLP999

Offset

How old were you the last time you experienced this insomnia (for at least one month)?

No

Yes

Unk

DASLP999

Do you currently experience insomnia?

0

1

9

Times per Week

DASLP999-DASLP999

How frequently do you experience insomnia?

DISTRESS/IMPAIRMENT

Please look at this scale from 0 to 10, where 0 means no distress/impairment and 10 means very severe problems.

Distress

Code Response

DASLP999

How much does your insomnia (sleep difficulties) upset or distress you?

Impairment

Code Response

DASLP999

Social

What number describes how much your insomnia has affected your social life or relationships with your friends?

Code Response

DASLP999

Family

What number describes how much your insomnia has affected your relationships with family members?

Code Response

DASLP999

School/Work

What number describes how much your insomnia has affected your performance in school/work or your relationships with your co-workers, employers, teachers or classmates?

NARCOLEPSY-CATAPLEXY

A. Daytime Sleepiness

No

Yes

Unk

DASLP999

1. Do you feel so sleepy during the day that it interrupts your normal activities – such as driving, reading, or concentrating at work or school, even when you have had enough sleep the night before?

0

1

9

Times per

Day

Week

Month

DASLP999-DASLP999

How often do you feel this way?

Weeks

Months

Years

DASLP999-DASLP999

What is the longest period of time that you have felt this way (on most days)?

No

Yes

Unk

DASLP999

2. During the daytime, do you experience an overwhelming desire to go to sleep – so overwhelming that you cannot resist?

0

1

9

Times per

Day

Week

Month

DASLP999-DASLP999

How often does this overwhelming desire to go to sleep occur?

Weeks

Months

Years

DASLP999-DASLP999

What is the longest period of time that you have felt this way (on most days)?

Never

Sometimes

Always

DASLP999

When you do doze off during the day and take a nap, do you find this sleep refreshing?

Describe:

___________________________________________

________________________________________ ________________________________________

0

1

2

Code Response

DASLP999

3. Do you feel that you are sleepier than other people your age?

0

1

2

9

0 = Not at all

1 = Somewhat

2 = A lot more sleepy

9 = Dont Know

B. Cataplexy

Do you ever experience periods of muscle weakness, loss of muscle strength or limp muscles in any part of your body (e.g. in the legs or face) during the following situations:

No

Yes

Unk

DASLP999

…when you laugh?

0

1

9

DASLP999

…when you are angry?

0

1

9

DASLP999

…when you hear or tell a joke?

0

1

9

REM SLEEP BEHAVIOR DISORDER

No

Yes

Unk

DASLP999

1. Have you ever been told that you "act out" your dreams?

0

1

9

Times per

Week

Month

Year

DASLP999-DASLP999

How often does this occur?

No

Yes

Unk

DASLP999

2. Do you ever move so much during your sleep that you accidentally hit your bed partner (if any) or hurt yourself?

0

1

9

If no to all (#1 and #2), SKIP to end

No

Yes

Unk

DASLP999

Do you have any memory of these event(s)?

0

1

9

DASLP999

Does moving at night disrupt your sleep? (i.e. wake you up at night)

0

1

9

First

Half

Second Half

DASLP999

During what part of the night do these events most often occur?

1

2