KUESIONAIRE SLEEP

Nama : Rizka Ramadhani Tanggal :

Jenis Kelamin : Perempuan No. HP : 1. 081283298929
Usia : 29 tahun 2.
Tanggal lahir : 17 Maret 1991 Lingkar leher :
BB : 100 Lingkar perut :
TB : 156 Semester/Tahap : 4/2
IMT : TD:

1. STOP-BANG

Yes No
Do you Snore Loudly (loud enough to be heard through closed doors or your bed-partner elbows you X
for snoring at night)?
Do you often feel Tired, Fatigued, or Sleepy during the daytime (such as falling asleep during driving X
or talking to someone)?
Has anyone Observed you Stop Breathing or Choking/Gasping during your sleep? x
Do you have or are being treated for High Blood Pressure? X
Body Mass Index more than 35 kg/m2? X
Age older than 50 year old? X
Neck size large? For male, is your shirt collar 17 inches/43 cm or larger? For female, is your shirt collar X
16 inches/41 cm or larger?
Gender = Male? X
Kesimpulan

2. Kuesioner Berlin

Kategori 1 (ditanyakan kepada orang yang melihat responden saat tidur)

1. Apakah anda mendengkur? a. Ya c. Tidak tahu
b. Tidak
2. Jika anda mendengkur, suara dengkuran anda : a. Sedikit lebih keras dibanding c. Lebih keras dibanding berbicara
bernafas d. Sangat keras, dapat terdengar
b. Sama kerasnya seperti berbicara sampai kamar sebelah
3. Seberapa sering anda mendengkur : a. Hampir tiap hari d. 1-2 kali per bulan
b. 3-4 kali per minggu e. Tidak pernah atau hampir tidak
c. 1-2 kali per minggu pernah
4. Apa suara dengkuran anda mengganggu orang lain? a. Ya c. Tidak tahu
b. Tidak
5. Pernahkah seseorang melihat atau memperhatikan bahwa a. Hampir tiap hari d. 1-2 kali per bulan
anda berhenti bernafas pada waktu tidur? b. 3-4 kali per minggu e. Tidak pernah atau hampir tidak
c. 1-2 kali per minggu pernah
Kategori 2
6. Berapa sering anda pernah merasa lelah atau kelelahan a. Hampir tiap hari d. 1-2 kali per bulan
saat bangun tidur? b. 3-4 kali per minggu e. Tidak pernah atau hampir tidak
c. 1-2 kali per minggu pernah
7. Selama anda terjaga di siang hari, apakah anda merasa a. Hampir tiap hari d. 1-2 kali per bulan
lelah, kelelahan atau tidak mencapai kondisi normal? b. 3-4 kali per minggu e. Tidak pernah atau hampir tidak
c. 1-2 kali per minggu pernah
8. Apakah anda pernah sangat mengantuk atau tertidur a. Hampir tiap hari d. 1-2 kali per bulan
ketika sedang mengemudi kendaraan? b. 3-4 kali per minggu e. Tidak pernah atau hampir tidak
c. 1-2 kali per minggu pernah
Kategori 3
9. Apakah anda mempunyai tekanan darah tinggi? Atau IMT a. Ya b. Tidak
> 30?
Kesimpulan

3. Insomnia Severity Index (ISI)

Insomnia Problems None Mild Moderate Severe Very Severe

1. Difficulty falling asleep 0 1 2 3 4
2. Difficulty staying asleep 0 1 2 3 4
3. Problems waking up too early 0 1 2 3 4
A Little Somewhat Much A Little Somewhat
4. How SATISFIED/DISSATISFIED are you with your 0 1 2 3 4
CURRENT sleep pattern?
Not at all A Little Somewhat Much Very Much
Noticeable Noticeable
5. How NOTICEABLE to others do you think your sleep 0 1 2 3 4
problem is in terms of impairing the quality of your
life?
6. How WORRIED/DISTRESSED are you about your 0 1 2 3 4
current sleep problem?
Not at all A Little Somewhat Much Very Much
Interfering Interfering
7. To what extent do you consider your sleep problem 0 1 2 3 4
to INTERFERE with your daily functioning (e.g.
daytime fatigue, mood, ability to function at
work/daily chores, concentration, memory, mood,
etc.) CURRENTLY?
Total
Kesimpulan

4. Pittsburgh Sleep Quality Index (PSQI)

1. When have you usually gone to bed? 22.00-23.00

2. How long (in minutes) has it taken you to fall asleep each night? 15
3. What time have you usually gotten up in the morning? 05
4. A. How many hours of actual sleep did you get at night? A. ____6-7 jam_______________________
B. How many hours were you in bed? B. _____8 jam______________________
5. During the past month, how often have you had trouble sleeping Not during the Less than once Once or twice a Three or more
because you past month a week week times a week
A. Cannot get to sleep within 30 minutes X
B. Wake up in the middle of the night or early morning X
C. Have to get up to use the bathroom X
D. Cannot breathe comfortably X
E. Cough or snore loudly X
F. Feel too cold X
G. Feel too hot X
H. Have bad dreams (SERING MIMPIP TAPI GA SAMPAI KEBANGUN) X
I. Have pain X
J. Other reason (s), please describe, including how often you have X
had trouble sleeping because of this reason (s): KEBANGUN UTK
KENCING 2 KALI SELAMA TIDUR MALAM
6. During the past month, how often have you taken medicine X
(prescribed or “over the counter”) to help you sleep?
7. During the past month, how often have you had trouble staying X
awake while driving, eating meals, or engaging in social activity?
8. During the past month, how much of a problem has it been for X
you to keep up enthusiasm to get things done?
9. During the past month, how would you rate your sleep quality Very good Fairly good Fairly bad Very bad
overall?
Kesimpulan

5. Epworth Sleepiness Scale (ESS)

Situation Would never doze Slight chance of Moderate chance High chance of
dozing of dozing dozing
Sitting and reading 0 1 2 3
Watching TV 0 1 2 3
Sitting inactive in a public place (e.g a theater or a 0 1 2 3
meeting)
As a passenger in a car for an hour without a break 0 1 2 3
Lying down to rest in the afternoon when 0 1 2 3
circumstances permit
Sitting and talking to someone 0 1 2 3
Sitting quietly after a lunch without alcohol 0 1 2 3
In a car, while stopped for a few minutes in traffic 0 1 2 3
Total
Kesimpulan

6. Reflux Symptom Index (RSI)

Within the last month, how did the following problems affect you? (0-5 rating scale with 0 = No problem and 5 = Severe)
1. Hoarseness or a problem with your voice 0 1 2 3 4 5
2. Clearing your throat 0 1 2 3 4 5
3. Excess throat mucous or postnasal drip 0 1 2 3 4 5
4. Difficulty swallowing food, liquids or pills 0 1 2 3 4 5
5. Coughing after you ate or after lying down 0 1 2 3 4 5
6. Breathing difficulties or choking episodes 0 1 2 3 4 5
7. Troublesome or annoying cough 0 1 2 3 4 5
8. Sensations or something sticking in your throat 0 1 2 3 4 5
9. Heart burn, chest pain, indigestion, or stomach acid coming up ga 0 1 2 3 4 5
Total Score
Kesimpulan

7. Sleep Hygiene Questionnaire

Never Rarely Sometimes Frequent Always

1. I take daytime naps lasting two or more hours 0 1 2 3 4
2. I go to bed at different times from day to day yes 0 1 2 3 4
3. I get out of bed at different times from day to day 0 1 2 3 4
4. I exercise to the point of sweating within 1 hr of going to 0 1 2 3 4
bed
5. I stay in bed longer than I should two or three times a week 0 1 2 3 4
6. I use alcohol, tobacco, or caffeine within 4hrs of going to 0 1 2 3 4
bed or after going to bed
7. I do something that may wake me up before bedtime (for 0 1 2 3 4
example: play video games, use the internet, or clean)
8. I go to bed feeling stressed, angry, upset, or nervous 0 1 2 3 4
9. I use my bed for things other than sleeping (for example: 0 1 2 3 4
watch television, read, eat, or study)
10. I sleep on an uncomfortable bed (for example: poor 0 1 2 3 4
mattress or pillow, too much or not enough blankets)
11. I sleep in an uncomfortable bedroom (for example: too 0 1 2 3 4
bright, too stuffy, too hot, too cold, or too noisy)
12. I do important work before bedtime (for example: pay bills, 0 1 2 3 4
schedule, or study)
13. I think, plan, or worry when I am in bed 0 1 2 3 4
Total

8. Kessler Psychological Distress Scale (K10)

None of A little of A little of Most of All of the

the time the time the time the time time
1. During the last 30 days, about how often did you feel tired out for no good 1 2 3 4 5
reason?
2. During the last 30 days, about how often did you feel nervous? 1 2 3 4 5
3. During the last 30 days, about how often did you feel so nervous that 1 2 3 4 5
nothing could calm you down?
4. During the last 30 days, about how often did you feel hopeless? 1 2 3 4 5
5. During the last 30 days, about how often did you feel restless or fidgety? 1 2 3 4 5
6. During the last 30 days, about how often did you feel so restless you could 1 2 3 4 5
not sit still?
7. During the last 30 days, about how often did you feel depressed? 1 2 3 4 5
8. During the last 30 days, about how often did you feel that everything was 1 2 3 4 5
 an effort?
9. During the last 30 days, about how often did you feel so sad that nothing 1 2 3 4 5
could cheer you up?
10. During the last 30 days, about how often did you feel worthless? 1 2 3 4 5
Total Score

9. Cognitive Failures Questionnaire (CFQ)

Never Very rarely Occasio Quite Very

nally often often
1. Do you read something and find you haven’t been thinking about it and must read 0 1 2 3 4
it again?
2. Do you find you forget why you went from one part of the house to the other? 0 1 2 3 4
3. Do you fail to notice signposts on the road? 0 1 2 3 4
4. Do you find you confuse right and left when giving directions? 0 1 2 3 4
5. Do you bump into people? 0 1 2 3 4
6. Do you find you forget whether you’ve turned off a light or a fire or locked the 0 1 2 3 4
door?
7. Do you fail to listen to people’s names when you are meeting them? 0 1 2 3 4
8. Do you say something and realize afterwards that it might be taken as insulting? 0 1 2 3 4
9. Do you fail to hear people speaking to you when you are doing something else? 0 1 2 3 4
10. Do you lose your temper and regret it? 0 1 2 3 4
11. Do you leave important letters unanswered for days? 0 1 2 3 4
12. Do you find you forget which way to turn on a road you know well but rarely use? 0 1 2 3 4
13. Do you fail to see what you want in a supermarket (although it’s there)? 0 1 2 3 4
14. Do you find yourself suddenly wondering whether you’ve used a word correctly? 0 1 2 3 4
15. Do you have trouble making up your mind? 0 1 2 3 4
16. Do you find you forget appointments? 0 1 2 3 4
17. Do you forget where you put something like a newspaper or a book? Sering 0 1 2 3 4
18. Do you find you accidentally throw away the thing you want and keep what you 0 1 2 3 4
meant to throw away – as in the example of throwing away the matchbox and
putting the used match in your pocket?
19. Do you daydream when you ought to be listening to something? 0 1 2 3 4
20. Do you find you forget people’s names? 0 1 2 3 4
21. Do you start doing one thing at home and get distracted into doing something 0 1 2 3 4
else (unintentionally)? Mungkin
22. Do you find you can’t quite remember something although it’s “on the tip of your 0 1 2 3 4
tongue”?
23. Do you find you forget what you came to the shops to buy? 0 1 2 3 4
24. Do you drop things? 0 1 2 3 4
25. Do you find you can’t think of anything to say? 0 1 2 3 4
Total Score

10. Internet Addiction Test (IAT) = PASIEN JARANG MENGGUNAKAN HP. HP HANYA DIGUNAKAN UNTUK SMS SAJA

Does Not Rarely Occasionally Frequently Often Always

Apply
1. How often do you find that you stay on-line longer than X
you intended?
2. How often do you neglect household chores to spend X
more time on-line?
3. How often do you prefer the excitement of the Internet X
to intimacy with your partner?
4. How often do you form new relationships with fellow X
on-line users?
5. How often do others in your life complain to you about X
the amount of time you spend online?
6. How often do your grades or school-work suffer X
because of the amount of time you spend on-line?
7. How often do you check your e-mail before something X
else that you need to do?
8. How often does your job performance or productivity X
 suffer because of the Internet?
9. How often do you become defensive or secretive when X
anyone asks you what you do on-line?
10.How often do you block out disturbing thoughts about X
your life with soothing thoughts of the Internet?
11.How often do you find yourself anticipating when you X
will go on-line again?
12.How often do you fear that life without the Internet X
would be boring, empty, and joyless?
13.How often do you snap, yell, or act annoyed if someone X
bothers you while you are on-line?
14.How often do you lose sleep due to latenight log-ins? X
15.How often do you feel preoccupied with the Internet X
when off-line, or fantasize about being on-line?
16.How often do you find yourself saying "just a few more X
minutes" when on-line?
17.How often do you try to cut down the amount of time X
you spend on-line and fail?
18.How often do you try to hide how long you've been on- X
line?
19.How often do you choose to spend more time on-line X
over going out with others?
20.How often do you feel depressed, moody, or nervous X
when you are off-line, which goes away once you are
back on-line?
Total
Kesimpulan

11. Bioelectrical Impedance Analysis (BIA) → dikosongkan

Pemeriksaan BIA
Body Weight
Body Fat (%)
Total Body Water (%)
Muscle Mass
Physique Rating
Visceral Fat (%)
BMR
Metabolic Age
Bone Mass