Patient Sleep Questionnaire

Please fill in this questionnaire to be submitted with a referral to the Sleep Clinic.

Contact Details

Personal Information

Sleep Apnoea Questionnaire
Snoring
1. Do you snore OR have you been told you snore? YesNo
2. Do you snore only when you are lying on your back? YesNo
3. Do you snore loudly? YesNo
4. Do you snore every night? YesNo
5. Has your partner had to move to another room during the night? YesNo

Obstrutive Sleep Apnoea
6. Have you been told you stop breathing or gasp during sleep? YesNo
7. Do you wake often to go to the toilet at night? YesNo
8. Do you doze off unintentionally during the day? YesNo
9. Do you often wake feeling tired? YesNo
10. Do you often wake in the morning with a headache or dry throat? YesNo
11. Do you have problems concentrating for long periods of time? YesNo
12. Do you easily forget things? YesNo
13. Have you noticed a decrease in work performance? YesNo
14. Have friends or family noticed a change in your personality? YesNo
15. Do you feel pain in your jaw joints (area of the ear)? YesNo
16. Do you grind or clench your teeth in your sleep? YesNo

Diagnosis and Treatment
17. Have you had or been treated for high blood pressure? YesNo
18. Have you had or been treated for diabetes? YesNo
19. Have you had or been treated for gastro-oesphageal reflux? YesNo
20. Have you had or been treated for anxiety or depression? YesNo
21. Have you even been diagnosed, or do you suspect you have OSA?* YesNo
22. Have you even been seen by a specialist for snoring or OSA?* YesNo
23. Have you ever had a sleep study?*
24. Have you ever been treated for snoring, OSA or a sleep disorder?* YesNo
* If yes, where and when?

Family History
25. Do you have any family members that have high blood pressure?** YesNo
26. Do you have any family member that have diabetes?** YesNo
27. Do you have any family members that have gastro-oesphageal reflux?** YesNo
28. Do you have any family members that have anxiety or depression?** YesNo
29. Do any family members snore, have OSA or a sleep disorder?** YesNo
** If yes, who?

Epworth Sleepiness Scale
How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? This refers to your usual way of life in recent times. Even if you have not done some of these things recently try to work out how they would have affected you. Use the following scale to choose the most appropriate number for each situation:
0 = Would never doze
1 = Slight chance of dozing
2 = Moderate chance of dozing
3 = High chance of dozing
Fill in the boxes to the right using the corresponding numbers above.

Activity

Sitting and reading
Watching television
Sitting, inactive in a public place (theater, meeting)
As a passenger in a car for an hour with no break
Lying down to rest in the afternoon, if circumstances permit
Sitting and talking to someone
Sitting quietly after lunch without alcohol
In a car while stopped for a few minutes in traffic
   
TOTAL SCORE:

STOP-BANG Questionnaire
Do you snore loudly (Louder than talking? Through closed doors?) YesNo
Do you often feel tired, fatigued, or sleepy during daytime? YesNo
Has anyone observed you stop breathing during your sleep? YesNo
Do you have or are you being treated for high blood pressure? YesNo
Do you have a BMI more than 35kg/m²? YesNo
Are you over 50 years old? YesNo
Is your neck circumference > 43cm (men) or > 41 (women)? YesNo
Are you male gender? YesNo

Your Signature