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Inpatient PSG Morning Questionnaire
Patient Name
Title
Please select...
Mr.
Mrs.
Ms.
Miss.
Master.
Dr.
Prof.
First name
Middle name
Surname
Maiden name (if applicable)
Date of Birth (DD/MM/YYYY)
Morning Questionnaire
In general, how well do you feel you slept last night when compared to your usual nights sleep?
Please select...
much worse than usual
worse than usual
slightly worse than usual
about the same as usual
slightly better than usual
better than usual
much better than usual
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?
Please select...
much longer than usual
long than usual
slightly longer than usual
same as usual
slightly shorter than usual
shorter than usual
much shorter than usual
How many times do you believe you woke from your sleep?
Please select...
0
1-2
2-3
3-4
5-6
7-8
9-10
10-15
15+
What disturbed your sleep last night? (Please tick as many as applicable)
Needing the bathroom
How many times?
Pain
Please describe the pain:
Discomfort
Please describe the discomfort:
Noise
Please describe the noise:
Disturbance from Technician
Please describe:
Other
Please describe disturbance:
How did you feel when you woke this morning?
Please select...
very tired and sleepy
a bit tired and sleepy
awake but not alert
awake but still a bit groggy
somewhat rested and awake
fairly rested and awake
alert and wide awake
Please add any additional comments related to your sleep:
Please rate the service you received between 0-5 (5 being the best score)
0
1
2
3
4
5
Please add any additional comments about the service:
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