Date of examination

yyyy-mm-dd

In recent one month, when did you go to bed?

o'clock

Scores

In recent month, how long did you need to sleep from the time of going to bed?

In recent month, when did you get up?

o'clock

Scores

In recent month, how many hours did you actually sleepness per night?

小时

Scores

In recent month, have you any of following situation to influence your sleep:

Difficulty falling asleep (cannot sleep within 30 min)

Easy to wake up at night or wake up early

Go to the toilet at night

Have difficulty in breathing

Cough or sound snore

Feel cold

Feel hot

Have a nightmare

Painful and uncomfortable

Any thing else to influence the sleep?

Totally, in recent one month, how do you think your sleep quality?

In past month, how about using medicine for your sleep?

In past one month, did you usually feeled sleepy and tired?

Compared to one year ago, how would you rate your health in general now?

Healthy and Daily activity

Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports

Moderate activities, such as moving a table, using a vacuum cleaner, bowling, or doing tai chi

Lifting or carrying groceries

Climbing several flights of stairs

Climbing one flight of stairs

Bending, kneeling, or stooping

Walking more than a kilometre

Walking several hundred metres

Walking one hundred metres

Bathing or dressing yourself

During the past 4 weeks, how much of the time have you had any of the following problems with your work or other regular daily activities as a result of your physical health?

Cut down on the amount of time you spent on work or other activities

Accomplished less than you would like

Were limited in the kind of work or other activities

Had difficulty performing the work or other activities (for example, it took extra effort)

During the past 4 weeks, how much of the time have you had any of the following problems with your work or other regular daily activities as a result of any emotional problems (such as feeling depressed or anxious)?

Cut down on the amount of time you spent on work or other activities

Accomplished less than you would like

Did work or other activities less carefully than usual

During the past 4 weeks, to what extent has your physical health or emotional problems interfered with your normal social activities with family, friends, neighbours, or groups?

How much bodily pain have you had during the past 4 weeks?

During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and housework)?

Did you feel full of life?

Have you been very nervous?

Have you felt so sad and low in mood that nothing could cheer you up?

Have you felt calm and peaceful?

Did you have a lot of energy?

Have you felt downhearted and depressed?

Did you feel worn out?

Have you been happy?

Did you feel tired?

During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your social activities (like visiting with friends, relatives, etc.)?

How TRUE or FALSE is each of the following statements for you?

I seem to get sick a little easier than other people

I am as healthy as anybody I know

I expect my health to get worse

My health is excellent

Doctor signature

Date of signature

yyyy-mm-dd

Medication

Specification

Unit

times/day

Reason

Start date

yyyymmdd

stop date

yyyymmdd