Insomnia Telephone Screening Script

1.

In the past six months and continuing up to the present day, have you had trouble sleeping?

Yes

No

2.

staying asleep?

Yes

No

3.

waking up too early?

Yes (If yes to any or all of 1-3, continue screening)

No (If no to 1-3 then ineligible)

4.

Do these/does this problem(s)make you feel sleepy and tired during the day?

Yes (Continue screening)

No (Ineligible)

5.

How frequently do/does your sleep problem(s) make you feel sleepy or tired during the day?

2-3 times or more a week (continue screening)

less than once or twice a week (Ineligible)

6.

Do you have unpleasant feelings in your legs when you go to bed (such as discofort or pricking sensations)?

Yes (Continue screening)

No(Eligible)

7.

Does this unpleasant feeling in your legs make it difficult to get to sleep at least 3 nights per week?

Yes (continue screening)

No (Eligible)

8.

Do you have disagreeable feelings of shivering or creeping in your calves?

Yes (Continue Screening)

No (Eligible)

9.

How often do you have disagreeable feelings of shivering or creeping in your calves?

Every Night (Continue Screening)

Several times per week (Continue Screening)

Several times per month (Continue Screening)

Once a month (Eligible)

Rarely(Eligible)

Never(Eligible)

10.

Are these sensations accompanied with pain in your legs?

Yes (Continue Screening)

No (Eligible)

11.

How often are these sensations accompanied with pain in your legs?

Always (Continue screening)

Sometimes (Continue screening)

Rarely (Eligible)

Never (Eligible)

12.

Does this disagreeable feeling or discomfort disappear when you move your legs?

Yes (Continue Screening)

No (Eligible)

13.

How often does this disagreeable feeling or discomfort disappear when you move your legs

Always (Ineligible)

Sometimes (Ineligible)

Rarely (Eligible)

Never (Eligible)

ISQ