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Wellvana Sleep
 
Sleep Questionnaire

Do you suspect you may be suffering from sleep apnoea?

Check your sleep or start the discussion with your doctor through this survey.

 

To qualify for Medicare benefits you must reach a certain score on at least 2 of 3 approved questionnaires.

To fast-track this process, you can complete these questionnaires here, and download the results to give to your doctor.

Regardless of the results, Wellvana Sleep can offer you support and services.

 

This form includes 2 questionnaires and will take approx. 3 mins to complete.

 

Questionnaire 1:

Epworth Sleepiness Scale

Questionnaire 1:

Epworth Sleepiness Scale
 
How likely are you to doze off or fall asleep in the following situations?
 
How likely are you to doze off or fall asleep in the following situations?
Sitting and reading:
Never
Slight
Moderate
High
Watching television:
Never
Slight
Moderate
High
Sitting inactive in a public place (e.g. Theatre or meeting):
Never
Slight
Moderate
High
As a passenger in a car for an hour without a break:
Never
Slight
Moderate
High
Lying down to rest in the afternoon when circumstances permit:
Never
Slight
Moderate
High
Sitting and talking to someone:
Never
Slight
Moderate
High
Sitting quietly after lunch without alcohol:
Never
Slight
Moderate
High
In a car as a driver stopped for a few minuets in traffic:
Never
Slight
Moderate
High

Questionnaire 2:

STOP-BANG

Questionnaire 2:

STOP-BANG
Do you snore loudly? Louder than talking or loud enough to be heard through closed doors?
Yes
No
Do you often feel tired, fatigued, or sleepy during the daytime?
Yes
No
Has anyone observed you stop breathing or choking/gasping during sleep?
Yes
No
Do you have (or are you being treated for) high blood pressure?
Yes
No
Do you have a BMI over 35 kg/m2?
Yes
No
Unknown (will be scored as 'no')
Are you older than 50 years of age?
Yes
No
Do you have a neck circumference* over 43 cm (male) / 41 cm (female)?
 
* Measured around Adams Apple
Yes
No
Unknown (will be scored as 'no')
Is your sex male?
Yes
No
What is your email address?
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