Sleep and Snoring Questionnaires

ALL SECTIONS OF THIS FORM MUST BE COMPLETED, THANK YOU.

These questionnaires help Dr Crawford to understand if you meet the Medicare requirements for direct referral for a home sleep study, rather than having to be referred to Sleep Physician, and assess how much your snoring and sleep disturbance is impacting on your life.

Please answer all questions as best you can.

How likely are you to doze off or fall asleep in the situations described below, in contrast to feeling just tired?

This refers to your usual way of life in recent times. Even if you have not done some of the things recently, try to work out how they would have affected you.

Situation

Never Slight Moderate High
Never Slight Moderate High
Never Slight Moderate High
Never Slight Moderate High
Never Slight Moderate High
Never Slight Moderate High
Never Slight Moderate High
Never Slight Moderate High

OSA 50 SCREENING QUESTIONNAIRE
Overall weight
Snoring
Apneas
Age
Rarely Some Nights (<50%) Most Nights (>50%) Every Night
Hardly at all Some of the night (<50%) Most of the night (>50%) All Night
Barely Audible Can be heard in the same room Can be heard in the next room Can be heard down the hall

Functional Outcome of Sleep Questionnaire

Instructions

Some people have difficulty performing everyday activities when they feel tired or sleepy. The purpose of this questionnaire is to find out if you generally have difficulty carrying out certain activities because you are too sleepy or tired.

In this questionnaire, when the words "sleepy" or "tired" are used, it means the feeling that you can't keep your eyes open, your head is droopy, that you want to "nod off", or that you feel the urge to take a nap. These words do not refer to the tired or fatigued feeling you may have after you have exercised.

Yes, extreme Yes, moderate Yes, a little No
Yes, extreme Yes, moderate Yes, a little No
Yes, extreme Yes, moderate Yes, a little No
Yes, extreme Yes, moderate Yes, a little No
Yes, extreme Yes, moderate Yes, a little No
Yes, extreme Yes, moderate Yes, a little No
Yes, extreme Yes, moderate Yes, a little No
Yes, extreme Yes, moderate Yes, a little No
Yes, extreme Yes, moderate Yes, a little No
Yes, extreme Yes, moderate Yes, a little No