Inpatient PSG Bedtime Questionnaire

Patient Name

Title

First name

Middle name

Surname

Maiden name (if applicable)

Date of Birth (DD/MM/YYYY)

Recent Medical Conditions

Have you recently had any of the following? (please select as many as applicable)

Bedtime Questionnaire

The following questions are to be completed based on the day of your sleep study.

Was the day of your study unusual in any way?

YesNo

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

Please list any prescribed medications you have taken within 24 hours of having your sleep study (if none, leave blank):
If you have recently completed the Sleep WA Sleep Questionnaire and already listed your medications once (and they remain the same), please write "as per Sleep Questionnaire".

	Medication	Dose	Time(s)
Complete all columns
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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:

Discharge

On Discharge, I will be:

Picked up by a friend/relativeDriving myself homeTaxi to work/homeOther

Please specify

Contact Information

Recent Eye Surgery	Recent Stroke	Pulmonary Embolism
Recent Thoracic / Abdominal Surgery	Recent Pneumothorax