Sleep Questionnaire - Ballina Health Ballina Health

Please enter your ID number*

Your ID number can be found on the letter your received containing this link

Current occupation*

If retired enter last occupation

Do you drive commercially

If yes, please select which type of driver suits you

If you selected other please specify

What are you work shift patterns

Who do you live with*

Do you snore*

If you do snore, how long have you snored (number of years)

If you snore, is the snoring getting worse?*

Is the snoring worse when you sleep on your back?*

Is the snoring worse after drinking alcohol the previous evening?

Does your snoring affect your partner's sleep?

Does your partner ever use ear plugs?

Does your partner sleep in the adjacent bedroom as a result of your snoring?

Has anyone commented that you stop breathing at night or have breath-holds?

Do you sometimes have a choking or gasping feeling at night when asleep?

On average what time do you go to sleep?

How long does it take to fall asleep on average once lights are out (in minutes)?

Do you think you wake up many times during the night?

If you do wake up through the night, what are the reasons?

Do you feel your night is restless?

Does your partner comment that your legs kick out or twitch during the night?

If you are restless, does it bother your partner?

On average what time do you get up in the morning?

Do you feel refreshed and ready to start the morning?

In general, how would you rate your sleep quality?

Do you tend to have a nap during the day?

Do you regularly fall asleep before midday, even when you are at work?

Do you feel during the day that you can't stop yourself having a nap or dozing off?

Do you feel less sleepy during the weekends or when you are on holidays?

If your main problem is excessive sleepiness during the day, how many years have you felt this way?

Do you experience feeling as if you can't move when you fall asleep (sleep paralysis)?

Do you experience that you start dreaming and sense you see things you can't explain (as if hallucinating) when asleep?

Do you feel that your jaw drops, or legs buckle and go weak when you are laughing or feeling angry? (also known as cataplexy)

Do you feel you thrush out during the night whilst dreaming?

Do you have any difficulty falling asleep?

Do you have any difficulty staying asleep?

Do you wake up too early?

How satisfied / dissatisfied are you with your CURRENT sleep pattern?

How noticeable to others do you think your sleep problem impairs your quality of life?

How worried or distressed are you about your current sleep problem?

To what extent do you CURRENTLY consider your sleep problem to interfere with your daily functioning - such as daytime fatigue, mood, ability to function at work or at home, concentration, memory etc.

In the last 7 days have you had the urge to move your legs or arms?

In the last 7 days when feeling the urge to move do you experience unpleasant sensations in your legs or arms such as tingling, burning, cramps, pain, creepy crawly feelings under the skin?

In the last 7 days does the urge to move or the presence of unpleasant sensations begin or worsen when you are at rest (lying/sitting), or when you are inactive?

In the last 7 days does moving partially or completely (eg walking or stretching) relieve the urge to move or improve the unpleasant sensations in your legs or arms?

Is the urge to move or having unpleasant sensations worsen in the evening and/or early part of the night compared to the day?

Do you think you have put on a lot of weight in the last few years?

Can you state how much weight and over how much time?

Do you have any of the following?

Have you ever had problems with your nose or throat that made you see a specialist such as an ENT?

If you have consulted an ENT, what was the reason?

Have you ever had an ENT operation, specify what operation and when?

Have you ever had surgery to your palate, specify what surgery and when?

What medications are you currently taking?

Are you allergic to any medications?

If you are allergic to any medications, please provide the medication name and the type of reaction?

Do you drink alcohol? If yes, how many standard drinks per week?

Epworth Sleep Questionnaire*

	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

This survey is a simple measure of how sleepy you are during the day. They are not a measure of how fatigued you are. It is a measure of sleepiness. On an ordinary day (assume you are not at work) in the noted situations, how likely are you to doze off to sleep?

Do you suffer from any of the following

If you experience any of the above, please note your age when this began, how often per week it occurs and if more than event per night, how many times a night?

If you experience sleep walking, night terrors or confusion arousals, do any of the following occur afterwards?