Sleep Questionnaire

Visit

32 Tamar St
Ballina NSW 2478
Australia

Contact

Phone: 02 6686 9199

International: +612 6686 9199

New Patients

Visiting Ballina Health Centre is a positive step toward rewriting your health journey and gaining an understanding and ownership of where you are right now with your health.

MORE INFORMATION

	Highly likely (score=3)	Moderately likely (score=2)	Slightly likely (score=1)	Never (score=0)
Sitting and reading
Watching TV
Sitting, inactive in a public place eg Theatre or meeting
As a passenger in a car for an hour without a break
Lying down to rest in the afternoon when circumstances permit
Sitting and talking to someone
Sitting quietly after lunch (no alcohol)
In a car, while stopped for a few minutes in the traffic

Sleep Questionnaire

Sleep Questionnaire

General questions

Snoring and breathing

Sleep – during the week

Do you have the following experiences?

Section Break

Visit

Contact

New Patients

bus
coach
salesperson
delivery driver
heavy vehicle
other

spouse
friend
family
alone
carer

Yes
No
Unsure

Yes
No
Unsure

Yes
No
Unsure

Yes
No
Unsure

Yes
No
N/A

Yes
No
NA

Yes
No
N/A

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No
N/A

Yes
No
N/A

Yes
No

usually good
sometimes good
rarely good
never good

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

None
Mild
Moderate
Severe
Very severe

None
Mild
Moderate
Severe
Very severe

None
Mild
Moderate
Severe
Very severe

Very satisfied
Satisfied
Moderately satisfied
Dissatisfied
Very dissatisfied

Not at all
A little
Somewhat
Much
Very much

Not at all
A little
Somewhat
Much
Very much

Not at all
A little
Somewhat
Much
Very much

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

Angina
Diabetes
High blood pressure
Previous strokes
Thyroid problems
Heartburn

Yes
No

Yes
No

Sleep walking
Night terrors
Confusion arousals
N/A

Eating
Scream
Run or escape
Dress into clothes
Be aggressive towards others
Are sexually aroused