Somnocare Sleep Questionnaire
Please complete all sections as accurately as possible
Submission Date
-
Day
-
Month
Year
Date Picker Icon
STOPBANG Score
OSA50 Score
OSA50 Apnoea
OSA50 Snore
OSA50 Age
OSA 50 Waist
SB Age
SB Gender
SB BMI
SB Neck
SB BP
SB Snore
SB Apnoea
First Name
*
Middle Name
Last Name
*
Gender
*
Male
Female
Other
Date of Birth
*
-
Day
-
Month
Year
Date Picker Icon
Age (Days)
Age (Years)
Height (cm)
*
Weight (kg)
*
Waist Circumference (cm)
*
Neck Circumference (cm)
*
BMI
Medical and General History
Please complete to the best of your knowledge
Please select whether you, or an immediate family member has had any of the following medical conditions:
Me
Immediate family member
Diabetes
Heart Disease
Irregular Hearth Rhythm
Congestive Heart Failure
Migraines
Hypertension
Hypothyroidism
Allergies/Sinusitis
Seizures/Epilepsy
Schizophrenia
Depression
Anxiety
Panic Disorder
Other (specify below)
Other medical conditions (if applicable)
Are you currently taking any prescribed medications?
*
Yes
No
Please list the medications you are currently taking:
*
What is your occupation?
Does your occupation involve shift work?
Yes
No
Please outline your typical roster
Do you drink alcohol?
*
Yes
No
On average, approximately how many standard drinks of alcohol do you consume per week
*
0-1
2-3
4-5
6-10
11-20
21-30
31-50
50+
On average, how many caffeinated beverages/products do you consume per day?
*
None
0-1
1-2
2-3
3-5
5+
Sleep Satisfaction
Please complete all fields to the best of your knowledge
How satisfied are you with your current sleep?
*
1
2
3
4
5
Very unsatisfied
Very satisfied
1 is Very unsatisfied, 5 is Very satisfied
How important is improving your sleep to you?
*
1
2
3
4
5
Not important
Very important
1 is Not important, 5 is Very important
Do you have any significant barriers preventing you from achieving adequate overall sleep and/or sleep duration?
*
Yes
No
In your own words, please describe any significant barriers preventing you from achieving adequate sleep
In general, how refreshing is your sleep the following day?
*
Very refreshing
Quite refreshing
Somewhat refreshing
Somewhat unrefreshing
Quite unrefreshing
Very unrefreshing
When you wake, do you still feel tired and would like to continue sleeping?
*
Never
Occasionally
Most mornings
Always
Sleep History
Please complete all questions to the best of your knowledge
What is your average bedtime?
*
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
What is your average wake time?
*
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Do you experience drowsiness while driving?
*
Yes
No
Do you snore, or have you ever been told you snore?
*
Yes
No
Would you classify your snoring as loud?
*
Yes
No
Has your snoring every bothered other people?
*
Yes
No
If you have a current sleeping partner, does your snoring bother them?
*
Yes
No
Don't have a sleeping partner
What sleeping position(s) does your snoring occur?
*
On my back (supine) only
In all positions
On my front or sides only
Unsure
Has anyone observed that you stop breathing, or that there is choking/gasping during the night?
*
Yes
No
Is your sleep restless?
*
Yes
No
How many times do you believe you typically wake up from sleep during a normal night?
*
Never wake
0-2
3-5
6-10
10+
What (if anything) typically disturbs or wakes you from your sleep (describe):
How often do you wake during the night to pass urine?
*
Never
Very occasionally
At least once per night
Multiple times per night
Do you ever wake with a headache?
*
Never
Occasionally
Fairly often
Very often
When you are at rest (typically nearing your sleep time), do you experience an irresistible urge or desire to move your legs or arms? This urge typically subsides following movement, but returns shortly after.
*
Yes
No
Overall, how would you rate the severity of this discomfort in your arms and legs?
*
1
2
3
4
5
Mild
Very severe
1 is Mild, 5 is Very severe
How often do experience this discomfort/urge to move your legs and/or arms?
*
Multiple times a day
Every night prior to sleep
Multiple times per week
About once per week
A few times per month
A few times per year
Do you have a history of sleep walking, or any other unusual movement behaviours during sleep?
*
Yes
No
Please describe or give examples of these unusual movement behaviours that occur during your sleep
*
How frequently do these unusual movement behaviours occur?
*
Less than once per month
A few times per month
At least once a week
Several times a week
Every night
Multiple times a night
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