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
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
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