Sleep Questionnaire

Patient Name
Recent Overseas Hospital Admissions
Usual Bedtime/Wake time

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

General Related Information
Smoking History
Alcohol and Caffeine
Medications

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

Medication  Dose Time(s)
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Medical History
Family Medical History


Did or does your mother/father or brother/sister suffer from: (please tick any applicable answers)

Partner related questions

If you have a current partner, if possible, please make sure they are here with you to complete this section

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
Patient Questions

The remainder of this questionnaire can be completed by the patient and no longer requires the patient's partner.

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
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
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.

OSA50 Survey