Dr Andrew Webster Patient Questionnaire

Patient Respiratory 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
CAT Score
MMRC 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)
Height (cm)*
Weight (kg)*
Waist girth (cm)*
Neck Girth (cm)*
BMI
Medical and General History

Please complete to the best of your knowledge
Are you currently taking any prescribed medications?*

YesNo
Please list the medications you are currently taking:*
Who lives at home with you? Please select all applicable*

MotherFatherBrotherSisterDaughter(s)Son(s)Spouse/PartnerRoom mate(s)Other
Do you have children?*

YesNo
What ages are your children?
Do you have any pets?*

YesNo
What pets do you have, and how long have you had them for?
Do you have any illnesses that run in your family? Select all that apply.*

No known illnessesLung DiseaseCancerAsthmaHeart diseaseOther
Please elaborate on the family illnesses specified above
Do you have, or are you being treated for high blood pressure?*

YesNo
Have you lost or gained any significant weight over the past 12 months (>5kg)?*

NoYes (gained weight)Yes (lost weight)
Approximately how much weight have you lost in the past 12 months?*

5-8kg9-12kg13-16kg17-20kg21-25kgMore than 25kg
Approximately how much weight have you gained in the past 12 months?*

5-8kg9-12kg13-16kg17-20kg21-25kgMore than 25kg
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 / Indigestion / Heart BurnIrritable bowel syndromeCoeliac diseaseOther
How many times per fortnight do you experience the reflux / heartburn

1-23-55-77-1010-1515+
Does the reflux / heartburn ever wake you from sleep?

YesNo
Neurological (please select all applicable)

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

DiabetesHigh cholesterolHypothyroidismAnaemiaOther
Other medical conditions (if applicable)
Other Respiratory History

Please complete to the best of your knowledge

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

Have you had sinus infections/nasal polyps?*

YesNo
Please provide additional information about your sinus infection/nasal polyps:
Do you get symptoms of postnasal drip?*

YesNo
How many times per week do you experience the postnasal drip?*

1-55-1015-2020-3030-4040+
Do you use any treatment for postnasal drip e.g. nasal sprays?*

YesNo
Please specify what treatment you are using for postnasal drip:
Do you have hay fever?*

YesNo
Do you wheeze?*

Never1-2 times per fortnight3-5 times per fortnight6-10 times per fortnightMore than 10 times per fortnight
Do you ever wake up wheezing?

Never1-2 times in the last fortnight3-5 times in the last fortnight6-10 times in the last fortnightMore than 10 times in the last fortnight
Do you have any allergies?*

YesNo
Have you had an allergy test, (skin prick/blood test) and do you know the result?*

NoYes and I know the resultYes but I don't know the result
What was the result of your allergy test?
Do you have a cough?*

YesNo
How many days per fortnight do you have a cough?*

1-23-45-67-89-1011-1213-14
Does your cough produce any sputum?*

YesNo
What color is the sputum?
How many tablespoons of sputum would you cough up per day?*

0-11-23-56-1011-15More than 15
Does your cough waken you from sleep?*

YesNo
Is your cough worse when you lie down?*

YesNoUnsure
Have you ever coughed up blood?*

YesNo
Are you, or have you recently been experiencing any shortness of breath?*

YesNo
Do you feel that your symptoms of shortness of breath have worsened over the past 12 months*

YesNoUnsure
The Modified Medical Research Council (MMRC) Dyspnoea Scale. Please select the option that best describes you normally:*

Not troubled by breathlessness except on strenuous exerciseShortness of breath when hurrying on the level or walking up a slight hillWalks slower than people of the same age on the level because of breathlessness, or has to stop for breath when walking at own pace on the level.Stops for breath after walking about 100m or after a few minutes on the levelToo breathless to leave the house or breathless when dressing or undressing.
When your chest is well/stable, how many times per day do you use your reliever medication e.g. Ventolin?*

I don't use any reliever medicationLess than once per day1 time per day1-2 times per day2-3 times per day3-4 times per day4-5 times per dayMore than 5 times per day
Are any symptoms of cough, wheeze or shortness of breath made worse by exposure to cold air, air conditioning or strong smells e.g. perfume/petrol?*

YesNo
Please specify/elaborate on the above:
Have you had any chest infections in the past 12 months?*

YesNo
Please state how many chest infections you have had in the last 12 months, when the last infection was and also if you have had any hospital admissions for chest infections:
COPD Assessment Test (CAT)

Please rate the severity of your respiratory symptoms below, with the lowest number being the mildest symptoms, and the highest number being the more severe symptoms.

	0	1	2	3	4	5

0 is I never Cough, 5 is I cough all the time

	0	1	2	3	4	5

0 is I have no phlegm (mucus) in my chest at all, 5 is My chest is completely full of phlegm (mucus)

	0	1	2	3	4	5

0 is My chest does not feel tight at all, 5 is My chest feels very tight

	0	1	2	3	4	5

0 is When I walk up a hill or one flight of stairs I am not breathless, 5 is When I walk up a hill or one flight of stairs I am very breathless

	0	1	2	3	4	5

0 is I am not limited doing any activities at home, 5 is I am very limited doing activities at home

	0	1	2	3	4	5

0 is I am confident leaving my home despite my condition, 5 is I am not at all confident leaving my home because of my lung condition

	0	1	2	3	4	5

0 is I sleep soundly, 5 is I don't sleep soundly because of my lung condition.

	0	1	2	3	4	5

0 is I have lots of energy, 5 is I have no energy at all

Lifestyle

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

YesNo
Occupational History

Please complete to the best of your knowledge
Please list all jobs that you have had including number of years employed in each of them. Specifically, please list any jobs that may have involved being exposed to irritants that could have damaged your lungs.
Have you been exposed to asbestos at any point?*

YesNoUnsure
Please give specific details about your exposure to asbestos, including type of exposure and duration, including housing.
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
Has anyone observed that you stop breathing, or that there is choking/gasping during the night?*

YesNo
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.*
Please add any additional relevant information that you believe may be useful to us
Should be Empty:

Patient Respiratory Questionnaire

Medical and General History

Other Respiratory History

COPD Assessment Test (CAT)

Lifestyle

Occupational History

Night-time Symptoms / Information

Epworth Sleepiness Scale (ESS)

Insomnia Severity Index