Short Form PROMIS-Sleep Disturbance

Claudia Jones,

Age: 27

Gender: Female

10th of July, 2017

What is your relationship with the individual if this questionnaire is completed by an informant?

How much time do you spend with the individual in a regular week? ________________ hours per week

How much (or how frequently) have you been disturbed by the following issues in the last TWO (2) WEEKS? None

Absolutely not. Slightly uncommon, less than a day Mild

a few days Moderate

More than half of the time Severe

Almost every day Domain with the highest score (clinician)

 I 1. Little interest or pleasure in doing things? 0 1 2 3 4 2 2. Feeling down, depressed, or hopeless? 0 1 2 3 4

 II 3. Feeling more irritated, grouchy, or angry than usual? 0 1 2 3 4 0

III 4. Sleeping less than usual, but still have a lot of energy? 0 1 2 3 4 4 5. Starting lots more projects than usual or doing more risky things than usual? 0 1 2 3 4 IV

6. Feeling nervous, anxious, frightened, worried, or on edge? 0 1 2 3 4 2 7. Feeling panic or being frightened? 0 1 2 3 4 8. Avoiding situations that make you anxious? 0 1 2 3 4 V 9. Unexplained aches and pains (e.g., head, back, joints, abdomen, legs)? 0 1 2 3 4 0 10. Feeling that your illnesses are not being taken seriously enough? 0 1 2 3 4

VI 11. Thoughts of actually hurting yourself? 0 1 2 3 4 4 VII 12. Hearing things other people couldn’t hear, such as voices even when no one was around?

0 1 2 3 4 0 13. Feeling that someone could hear your thoughts, or that you could hear what another person was thinking?

0 1 2 3 4 VIII

14. Problems with sleep that affected your sleep quality over all? 0 1 2 3 4 4 IX 15. Problems with memory (e.g., learning new information) or with location (e.g., finding your way home)?

0 1 2 3 4 0 X

16. Unpleasant thoughts, urges, or images that repeatedly enter your mind?

0 1 2 3 4 4

17. Feeling driven to perform certain behaviors or mental acts over and over again?

0 1 2 3 4 XI 18. Feeling detached or distant from yourself, your body, your physical surroundings, or your memories?

0 1 2 3 4 1 XII 19. Not knowing who you really are or what you want out of life?

0 1 2 3 4 0 20. Not feeling close to other people or enjoying your relationships with them?

0 1 2 3 4 XIII 21. Drinking at least 4 drinks of any kind of alcohol in a single day?

0 1 2 3 4 0

22. Smoking any cigarettes, a cigar, or pipe, or using snuff or chewing tobacco?

0 1 2 3 4 23. Using any of the following medicines ON YOUR OWN, that is, without a doctor’s prescription, in greater amounts or longer than prescribed [e.g., painkillers (like Vicodin), stimulants (like Ritalin or Adderall), sedatives or tranquilizers (like sleeping pills or Valium), or drugs like marijuana, cocaine or crack, club drugs (like ecstasy), hallucinogens (like LSD), heroin, inhalants or solvents (like glue), or methamphetamine (like speed)]?

0 1 2 3 4