Dr Andrew Webster Patient Questionnaire

Patient Sleep Questionnaire

Please fill out all questions if possible, and be as specific as you can. This will allow the doctor to focus more specifically on your particular situation and allow them to make the most of the consult.
Submission Date

DayMonthYear
PHQ-9 Score
ISI Score
ESS Score
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
SB Tired
First Name*
Middle Name
Last Name*
Gender*
Date of Birth*

DayMonthYear
Age (Days)
Age (Years)
Have you been referred as part of a work place medical or for corporate purposes?

YesNo
Height (cm)*
Weight (kg)*
Waist Girth (cm)*
Neck Girth (cm)*
BMI
Medical and General History

Please complete to the best of your knowledge
Do any of your immediate family members (mother/father/brother/sister) have sleeping disorders?

YesNo
Please specify which family member and what sleeping disorder they have:
Do you have, or are you being treated for high blood pressure?*

YesNo
Medical conditions (please select all applicable)

Breathing/Respiratory: (e.g. Asthma, COPD, emphysema, other)Heart: (e.g. palpitations, heart failure/attack, other)Psychological: (e.g. Anxiety, depression, PTSD, Bi-Polar, Panic disorder, ADHD, other)Rheumatologic: (e.g. Fibromyalgia, chronic fatigue syndrome, osteo/rheumatoid arthritis, other)Digestive: (e.g. Reflux, Indigestion, Irritable bowel syndrome, coeliac disease, other)Neurological: (e.g. Epilepsy, seizures, blackouts, stroke, migraines, Parkinson's)Endocrine: (e.g. Diabetes, high cholesterol, hypothyroidism, anaemia)
Breathing / Respiratory condition (please select all applicable):

AsthmaCOPDEmphysemaOther
Heart / Cardiac condition (please select all applicable)

AnginaPalpitationsHeart failurePrevious heart attackOther
Psychological (please select all applicable)

AnxietyDepressionPost traumatic stress disorderBi-PolarPanic disorderADHDOther
Rheumatologic (please select all applicable)

FibromyalgiaChronic fatigue syndromeOsteo/rheumatoid arthritisOther
Digestive (please select all applicable)

Reflux / IndigestionIrritable bowel syndromeCoeliac diseaseOther
Neurological (please select all applicable)

Epilepsy / SeizuresBlackoutsStrokeMigrainesParkinson'sOther
Endocrine (please select all applicable)

DiabetesHigh cholesterolHypothyroidismAnaemiaOther
Other medical conditions (if applicable)

Sinus history - do you have any of the following?

	Select all applicable
Regular nasal congestion
Nasal or sinus problems
Nasal fractures
Previous nasal surgery
Allergies

Are you currently taking any prescribed medications?*

YesNo
Please list the medications you are currently taking:*
Have you ever used medications to sleep?*

Yes (currently using)Yes (previously used)No
Please specify which medication(s) you have used/are using to assist with sleep:
Have you gained/lost any significant weight (>5kg) in the last two years?

NoYes (gained weight)Yes (lost weight)
Approximately how much weight have you gained in the last two years?

5-10kg10-15kg15-20kg20-25kg25-30kg30-40kg40+ kg
Approximately how much weight have you lost in the last two years?

5-10kg10-15kg15-20kg20-25kg25-30kg30-40kg40+ kg
Do you drink alcohol?*

YesNo
On average, approximately how many standard drinks of alcohol do you consume per week*

0-12-34-56-1011-2021-3031-5050+
On average, how many stimulant drinks you consume per day (coffee/tea/cola/energy drinks)?*

None0-11-22-33-55+
What time do you typically have your latest stimulant drink (select the more applicable answer)?

Before 12pmBetween 12pm and 2pmBetween 2pm and 4pmBetween 4pm and 6pmBetween 6pm and 8pmAfter 8pm
Smoking status:

Never smokedEx-SmokerSmoker
In total, how many years did you smoke for?

Less than 1 year1-2 years2-5 years5-10 years10-20 years20-30 years30+ years
How many years has it been since you last smoked?

Less than 1 year1-2 years2-5 years5-10 years10-20 years20-30 years30+ years
On average, how many cigarettes did you smoke per day?

Less than 55-1010-2020-3030-4040-5050+
In total, how many years have you smoked for?

Less than 1 year1-2 years2-5 years5-10 years10-20 years20-30 years30+ years
On average, how many cigarettes do you smoke per day?

Less than 55-1010-2020-3030-4040-5050+
Do you take any recreational drugs?

YesNo
Please specify which recreational drugs you take:
Roughly how many times per week do you engage in dedicated physical activity/exercise

Never0-11-23-45-66-88+
Please specify the type of exercise(s) you engage in
Occupation
What is your occupation?
Does your occupation involve shift work?

YesNo
Please outline your typical roster
Sleeping Patterns

Please complete all fields to the best of your knowledge
What is your average bedtime on weekends?*

:HourMinutesAM/PM Option
What is your average wake time on weekends?*

:HourMinutesAM/PM Option
What is your average bedtime time on weekdays?*

:HourMinutesAM/PM Option
What is your average wake time on weekdays?*

:HourMinutesAM/PM Option
Do you consider yourself to be a "morning person" or a "night person"?

NeutralMorning person (lark)Night person (owl)
On average, approximately how many total hours of sleep do you feel you get per night?*

Less than 22-44-55-66-77-88-99+
Do you have trouble getting to sleep?*

YesNo
What do you think is/are the main reason(s) you have trouble getting to sleep? (Select as many as applicable)

NoiseNot tiredCan't switch offMind racingStressAnxietyAches and painsQuality of bed / poor sleeping environmentToo hot or too coldMedicationOther
On average, on a typical night, approximately how long do you believe it takes you to fall asleep?*

Less than 5 minutes5-10 minutes10-20 minutes20-30 minutes30-60 minutes1-2 hoursMore than 2 hours
On average, approximately how much time do you believe you spend awake during the night, after you have initiated sleep?*

Less than 15 minutes15-30 minutes30-60 minutes1-2 hours2-3 hours3-4 hoursMore than 4 hours
How many times do you believe you typically wake up from sleep during a normal night?*

Never wake0-23-56-1010+
What typically disturbs or wakes you from your sleep (describe):
Do you consider yourself to be a restless sleeper?*

YesNo
Do you feel you get enough sleep on a typical night?*

YesNo
What is your preferred sleeping position?*

SideBackSide and backFrontAll sleeping positions

How important is improving your sleep to you?*

	1	2	3	4	5

1 is Not important, 5 is Very important

Please add any additional information regarding your sleeping patterns that you believe may be useful:
Daytime Symptoms

Please complete all questions to the best of your knowledge
Do you often feel tired, fatigued or sleepy during the daytime?*

YesNo

Over a 14-day period, what percentage of days do you:

	0%	0-20%	20-40%	40-60%	60-80%	80-100%	100%
Wake feeling unrefreshed
Wake with a headache
Feel fatigued during the day
Feel your memory/concentration is reduced
Feel irritable
Have daytime naps

Has your driving been affected by sleepiness in the past 12 months (e.g. dozing at lights/needing to pull over)?*

YesNo
Please describe/give examples of how your driving has been affected (please be as specific as possible)
Is/has your work or occupation been affected by your sleepiness at anytime?*

YesNoI don't work
Please describe how your sleepiness has been affecting your work/occupation:
Have you ever experienced sudden transient weakness brought on by laugher or other emotions that affect your whole body or part of your body (i.e. just your legs)?*

YesNo
How often do these episodes of sudden transient weakness occur?*

RarelySometimesFrequently
Please add any additional information about your day-time symptoms/habits that you believe would be relevant:
Night-time Symptoms / Information

Please complete all questions to the best of your knowledge
Do you snore, or have you ever been told you snore?*

YesNo
Would you classify your snoring as loud?*

YesNo
Has your snoring ever bothered other people?*

YesNo
If you have a current sleeping partner, does your snoring bother them?*

YesNoDon't have a sleeping partner
How often does your snoring bother your partner?

Very OccasionallyOccasionallySometimesOftenVery often
What sleeping position(s) does your snoring occur?*

On my back (supine) onlyIn all positionsOn my front or sides onlyUnsure
Has anyone observed that you stop breathing, or that there is choking/gasping during the night?*

YesNo
How often has your partner/other person witnessed this choking/gasping during the night?

Very OccasionallyOccasionallySometimesOftenVery often
How often do you wake during the night to pass urine?*

Never1-2 times per night3-4 times per nightMore than 4 times per night
How often do you wake with a panic attack?*

NeverOccasionallyFrequently
How often do you wake with a bitter taste/reflux?*

NeverOccasionallyFrequently
Do you know, or have you been told, that you grind your teeth while sleeping?*

YesNo
When you try to relax in the evening or to sleep at night, do you ever have unpleasant, restless feelings in your legs or arms that can be relieved by walking or movement?*

YesNo
How often do experience this unpleasant, restless feeling in your legs and/or arms?*

Multiple times a dayEvery dayMultiple times per weekAbout once per weekA few times per monthA few times per year

Have you ever been told, or suspected yourself, that you seem to "act out your dreams" while you sleep? e.g. punching, flailing your arms in the air, kicking, running movements, etc.*

YesNo
Please describe or give examples of these unusual movement behaviours that occur during your sleep*
How frequently do these unusual movement behaviours occur?*
Do you have a history of, or have you ever been told that you sleep walk?*

YesNo
Please describe your sleep walking episodes including their frequency and most recent episode:

Have you experienced any of the following?*

	Never	Rarely	Sometimes	Frequently
Nightmares
Woken at night feeling paralysed/unable to move
Seeing things/hearing voices at night

Please add any additional information regarding your night-time information that you believe may be useful:
Epworth Sleepiness Scale (ESS)

In the following situations, please rate how likely you are to fall asleep
Sitting and reading*
Watching TV*
Sitting quietly after lunch without alcohol*
Sitting and talking to someone*
Sitting quietly in a public place*
Lying down to rest in the afternoon*
As a passenger in a car for an hour without a break*
In a car stopped in traffic*
Insomnia Severity Index

Please answer the following questions based on your current sleep perceptions (approximately the last two weeks).
Please rate how SEVERE your difficulty in falling asleep is:*
Please rate how SEVERE your difficulty staying asleep is:*
Please rate how SEVERE your problem waking too early in the morning is:*
How SATISFIED are you with your current sleep pattern?*
How NOTICEABLE to others do you think your sleep problem is in terms of impairing your quality of life*
How WORRIED/DISTRESSED are you about your current sleeping problem*
To what extent do you consider your current sleep problem to INTEREFERE with your daily functioning (e.g. daytime fatigue/mood/ability to work/concentration/memory etc.*
Patient Health Questionnaire (PHQ-9)

Sleep disorders can increase symptoms of depression and anxiety. Filling this portion of the questionnaire will help determine the effects your sleep are having on your mood. Please only fill this out if you feel comfortable doing so.
I am comfortable completing this survey*

YesNo
Over the last 14 days, how often have you been bothered by the following situations:
Little interest or pleasure doing things?*
Feeling down, depressed or hopeless?*
Trouble falling or staying asleep, or sleeping too much?*
Feeling tired or having little energy?*
Poor appetite or over eating?*
Feeling bad about yourself - or that you are a failure or have let yourself or your family down?*
Trouble concentrating on things, such as reading the newspaper or watching television?*
Moving or speaking so slowly that other people could have noticed? Or so fidgety or restless that you have been moving a lot more than usual?*
Thoughts that you would be better off dead, or thoughts of hurting yourself in some way? *
Please add any additional relevant information that you believe may be useful to us
Should be Empty:

Patient Sleep Questionnaire

Medical and General History

Occupation

Sleeping Patterns

Daytime Symptoms

Night-time Symptoms / Information

Epworth Sleepiness Scale (ESS)

Insomnia Severity Index

Patient Health Questionnaire (PHQ-9)