Home Sleep Study Diary

Patient Name

Title

First name

Middle name

Surname

Maiden name (if applicable)

Date of Birth (DD/MM/YYYY)

General Information

What location did you undergo your home based sleep study hook-up?

Height (cms)

Weight (Kgs)

Neck Circumference (cms)

Waist Circumference (cms)

Have you had previous ENT Surgery?

YesNo

Type of surgery (Please describe)

Year of Surgery

Are you currently using dentures?

YesNo

Top Dentures

Bottom Dentures

Bedtime Questionnaire

The following questions are to be completed based on the day of your sleep study hook-up

Please complete your closest estimation of the time you believe you got into bed, followed by the time you started attempting sleep:

	Hours	Minutes	AM / PM
Time got into Bed:
Time attempted sleep:

Did you read, watch television or do anything else prior to attempting sleep?

YesNo

Was the day of your study unusual in any way?

YesNo

Please describe your unusual day and why it had an affect on you:

Have you taken any prescribed medications within 24 hours of having your sleep study?

YesNo

Medications

Please list any prescribed medications

	Medication	Dose	Time(s)
Complete all columns
Complete all columns
Complete all columns
Complete all columns
Complete all columns
Complete all columns
Complete all columns
Complete all columns
Complete all columns
Complete all columns

Did you nap during the day of your sleep study?

YesNo

	Hours	Minutes	AM / PM
Time of nap

Length of nap (Minutes)

Did you consume any caffeine the day of your sleep study? (note: includes tea/coffee/energy drinks/chocolate etc.)

YesNo

Please describe the type and the amount:

Did you consume any alcohol the day of your sleep study?

YesNo

Approximately how many standard drinks?

Are you/have you been experiencing any pain or discomfort the day of your sleep study?

YesNo

Please describe your pain/discomfort:

Morning Questionnaire

To be filled out based on how you perceived the night of your home based sleep study

What time did you wake up this morning and cease sleep? (answer as closely as possible)

	Hours	Minutes	AM / PM
Wake Time

In general, how well do you feel you slept last night when compared to your usual nights sleep?

How long do you believe it took you to fall asleep last night?

How long did it take you to fall asleep last night, when compared with a normal night?

How many times do you believe you woke from your sleep?

What disturbed your sleep last night? (Please tick as many as applicable)

Needing the bathroom

How many times?

Pain

Please describe pain:

Discomfort

Please describe discomfort:

Noise

Please describe noise:

Disturbance from Partner

Please describe disturbance:

Other

Please describe other disturbance:

How did you feel when you woke this morning?

Please add any additional comments related to your sleep:

Please add any additional comments about the service:

Contact Information