Sleep Questionnaire

Patient Name

Title

First name

Middle name

Surname

Maiden name (if applicable)

Date of Birth (DD/MM/YYYY)

Weight (kg)

Height (cm)

Hospital Pre-Admission Declaration

Have you been admitted to a Hospital outside Australia in the last 12 months?

YesNo

Please list these hospitals, including the date(s) of admission

Do you have a communicable disease

YesNo

Please enter communicable disease details:

Usual Bedtime/Wake time

Note: Please enter your closest approximation of your usual bedtime and wake time

Bed Time Hours

Bed Time Minutes

Bed Time AM / PM

Wake Time Hours

Wake Time Minutes

Wake Time AM / PM

General Related Information

What is your occupation?

Does your occupation involve shift work?

YesNo

Describe your typical roster (be as specific as possible)

Does your occupation involve driving or operating heavy machinery?

YesNo

Have you ever experienced drowsiness while driving?

YesNo

When did this last occur?

How frequently do you experience drowsiness while driving?

How often have you had to pull to the side of the road because of fatigue?

Are you dealing with any life stressors that you think are significant?

YesNo

Please list these significant life stressors

On a scale of 1-5, please rate the cumulative impact of these stressors on your life (0 = no impact, 5 = maximum impact)

Smoking History

Smoking Status (please select an option)

On average, how many cigarettes did you/do you smoke per day?

How many years since you last smoked?

Alcohol and Caffeine

Do you consume alcohol?

YesNo

Approximately how many standard drinks, on average, per week?

Do you consume caffeine?

YesNo

Approximately how many cups of tea or coffee per day?

Medications

Please list any prescribed medications (if none, leave blank)

	Medication	Dose	Time(s)
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Partner Epworth Sleepiness Scale

Note: This is to be completed by the patient's partner, based on how they perceive the patient's level of sleepiness.

In the following situations, please choose how likely your partner (the patient) is to doze or fall asleep:

	Never Doze/Not Applicable	Slight Chance of Dozing	Moderate Chance of dozing	High Chance of Dozing
1. Sitting and Reading.
2. Watching TV
3. Sitting quietly in a public place (e.g. meeting or theatre)
4. As a passenger in a car for an hour without a break
5. Lying down to rest in the afternoon, when circumstances permit
6. Sitting and talking to someone
7. Sitting quietly after lunch without alcohol
8. In a car, while stopped for a few minutes in traffic

Patient Epworth Sleepiness Scale

Note: This is to be completed by the patient, about themselves.

In the following situations, please choose how likely you are to doze or fall asleep by selecting the most applicable box:

	Never Doze/Not Applicable	Slight Chance of Dozing	Moderate Chance of dozing	High Chance of Dozing
1. Sitting and Reading
2. Watching TV
3. Sitting quietly in a public place (e.g. meeting or theatre)
4. As a passenger in a car for an hour without a break
5. Lying down to rest in the afternoon, when circumstances permit
6. Sitting and talking to someone
7. Sitting quietly after lunch without alcohol
8. In a car, while stopped for a few minutes in traffic

Major Depression Index [MDI]

The following questions ask about how you have been feeling over the last two weeks. Please mark the box which is closest to how you have been feeling.

	None of the time	Some of the time	Less than half of the time	More than half of the time	Most of the time	All of the time
1. Have you felt low in spirits or sad?
2. Have you lost interest in your daily activities
3. Have you felt lacking in energy or strength?
4. Have you felt less self-confident
5. Have you had a bad conscience or feelings of guilt?
6. Have you felt that life isn't worth living?
7. Have you had difficulty in concentrating?
8a. Have you felt very restless?
8b. Have you felt subdued
9. Have you had trouble sleeping at night?
10a. Have you suffered from reduced appetite?
10b. Have you suffered from increased appetite?

Insomnia Severity Index (ISI)

For each question, please rate the current severity of your sleep problem by selecting the most appropriate response from the drop down list.

Please rate the severity of your difficulty in falling asleep:

Please rate the severity of your difficulty in staying asleep:

Please rate your problem waking up too early in the morning:

Please rate how SATISFIED you are with your current sleep pattern:

Please rate how your sleep problem INTERFERES with your daily functioning, i.e. daytime fatigue, concentration, mood, ability to function at work, ability to complete tasks at home, etc:

Please rate the extent to which your sleep problem is NOTICEABLE to others:

How WORRIED/DISTRESSED are you about your current sleep problem:

OSA50 Survey

Obese

Is your waist circumference >102cm (males) or 88cm (females)?

Snoring

Is your snoring disruptive to anyone?

Apnoeas

Has anyone witnessed pauses in breathing during sleep?

Are you 50 years or older?

Contact Information

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