Pitsburgh Sleep Quality Index

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Form Administration Instructions

The range of values for questions 5 through 10 are all 0 to 3.

Questions 1 through 9 are not allowed to be missing except as noted below.  If these questions are missing then any scores calculated using missing questions are also missing.  Thus it is important to make sure that all questions 1 through 9 have been answered. 

In the event that a range is given for an answer (for example, ‘30 to 60’ is written as the answer to Q2, minutes to fall asleep), split the difference and enter 45.

Reference

Buysse DJ, Reynolds CF, Monk TH, Berman SR, Kupfer DJ:  The Pittsburgh Sleep Quality Index:  A new instrument for psychiatric practice and research.  Psychiatry Research 28:193-213, 1989.

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Barthel Index Instrument

THE                                   Patient Name: ___________________________ 

BARTHEL                                   Rater Name: ___________________________ 

INDEX                                            Date: ___________________________

Activity Score

FEEDING

0 = unable

5 = needs help cutting, spreading butter, etc., or requires modified diet

10 = independent

            ______  

BATHING

0 = dependent

5 = independent (or in shower)  ______ 

GROOMING

0 = needs to help with personal care

5 = independent face/hair/teeth/shaving (implements provided)  ______

DRESSING

0 = dependent

5 = needs help but can do about half unaided

10 = independent (including buttons, zips, laces, etc.)  ______ 

BOWELS

0 = incontinent (or needs to be given enemas)

5 = occasional accident

10 = continent ______ 

BLADDER

0 = incontinent, or catheterized and unable to manage alone

5 = occasional accident

10 = continent ______ 

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