Sleep Study Questionnaire Leave this field empty Step 1 of 6 About you Please answer these questions before you return your sleep study equipment. It takes about five minutes. Your answers go straight to the sleep scientist reading your study. Your full name Please enter your name. Your date of birth Please enter your date of birth. Which pronouns should we use when we write about you?We use this only when writing your sleep study report, so that it refers to you correctly.She / herHe / himThey / themPrefer to self-describePrefer not to sayPlease tell us which pronouns to useFor example: she / they, or ze / zir.Please add a few words here.Please answer this question. The night you wore the equipment If you slept with it last night, choose yesterday's date. Please tell us which night you wore the equipment. Your height cm Please enter your height in centimetres. Your weight kg Please enter your weight in kilograms. How likely are you to doze off? How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? This refers to your usual way of life in recent times. Even if you haven't done some of these things recently, try to work out how they would have affected you. Sitting and reading Would never dozeSlight chance of dozingModerate chance of dozingHigh chance of dozing Please choose one answer. Watching TV Would never dozeSlight chance of dozingModerate chance of dozingHigh chance of dozing Please choose one answer. Sitting, inactive, in a public place (e.g. a theatre or a meeting) Would never dozeSlight chance of dozingModerate chance of dozingHigh chance of dozing Please choose one answer. As a passenger in a car for an hour without a break Would never dozeSlight chance of dozingModerate chance of dozingHigh chance of dozing Please choose one answer. Lying down to rest in the afternoon when circumstances permit Would never dozeSlight chance of dozingModerate chance of dozingHigh chance of dozing Please choose one answer. Sitting and talking to someone Would never dozeSlight chance of dozingModerate chance of dozingHigh chance of dozing Please choose one answer. Sitting quietly after lunch, without alcohol Would never dozeSlight chance of dozingModerate chance of dozingHigh chance of dozing Please choose one answer. In a car, while stopped for a few minutes in the traffic Would never dozeSlight chance of dozingModerate chance of dozingHigh chance of dozing Please choose one answer. How you have been feeling These questions help us understand how you have been feeling during the past week. Don't think about your answers too much — your first reaction is usually the most useful one. I feel tense or 'wound up' Most of the timeA lot of the timeFrom time to time, occasionallyNot at all Please choose one answer. I still enjoy the things I used to enjoy Definitely as muchNot quite so muchOnly a littleHardly at all Please choose one answer. I get a sort of frightened feeling as if something awful is about to happen Very definitely and quite badlyYes, but not too badlyA little, but it doesn't worry meNot at all Please choose one answer. I can laugh and see the funny side of things As much as I always couldNot quite so much nowDefinitely not so much nowNot at all Please choose one answer. Worrying thoughts go through my mind A great deal of the timeA lot of the timeFrom time to time, but not too oftenOnly occasionally Please choose one answer. I feel cheerful Not at allNot oftenSometimesMost of the time Please choose one answer. I can sit at ease and feel relaxed DefinitelyUsuallyNot oftenNot at all Please choose one answer. I feel as if I am slowed down Nearly all the timeVery oftenSometimesNot at all Please choose one answer. I get a sort of frightened feeling like 'butterflies' in the stomach Not at allOccasionallyQuite oftenVery often Please choose one answer. I have lost interest in my appearance DefinitelyI don't take as much care as I shouldI may not take quite as much careI take just as much care as ever Please choose one answer. I feel restless as if I have to be on the move Very much indeedQuite a lotNot very muchNot at all Please choose one answer. I look forward with enjoyment to things As much as I ever didRather less than I used toDefinitely less than I used toHardly at all Please choose one answer. I get sudden feelings of panic Very often indeedQuite oftenNot very oftenNot at all Please choose one answer. I can enjoy a good book or radio or TV programme OftenSometimesNot oftenVery seldom Please choose one answer. The night you wore the equipment Your best estimate is fine — we don't expect you to have watched the clock. What time did you turn your lights off to sleep last night?Please answer this question.What time did you get up this morning?Please answer this question.How elevated were you while sleeping last night?Lay flat1 pillow2 pillows3 pillows4 or more pillowsSat uprightPlease answer this question.How long do you think it took you to fall asleep last night?minutesPlease answer this question.How long do you think you slept last night?hoursPlease answer this question.How did the quality of your sleep last night compare to your usual sleep?BetterThe sameWorsePlease answer this question.How did this compare to the length of time you usually sleep at home?LessSimilarLongerPlease answer this question.How do you feel at this moment?RestedAwake and alertAwake but not alertVery sleepy and unrestedPlease answer this question.Did you take any medication yesterday or during the night?Please include anything you buy without a prescription, and anything herbal.NoYesWhat did you take, and roughly when?The dose is helpful if you know it. For example: Metformin 500 mg with dinner, Temazepam 10 mg at bedtime.Please add a few words here.Please answer this question.Did you wear any device in your mouth or nose overnight?For example a mouthguard, a dental splint that moves your jaw forward, or a nasal strip or dilator. This does not include your sleep study equipment.NoYesWhat was it, and what time did you put it in and take it out?For example: mouthguard from my dentist, in at 10:30 pm, out at 6:30 am.Please add a few words here.Please answer this question. Is there anything else you would like the sleep scientist to know? Optional. For example, if something unusual happened during the night. How did we do? These last two questions are about the service, not your sleep. They help us improve how we run home studies, and they make no difference to your results. How would you rate the service you received? optional5 - Very good4 - Good3 - Satisfactory2 - Poor1 - UnsatisfactoryPlease answer this question.Is there anything we could have done better? optionalPlease answer this question. Almost done Please check your name and date of birth are correct, then send your answers. Your answers are sent securely to Epworth Sleep Centre and stored with your sleep study record. They are used only for your clinical care. Back Next Send my answers Sending…
