Sleep apnoea questionnaire

Step 1 of 2

What is your name?  Required
What is your date of birth?  Required
What is your sex?  Required

Epworth Sleepiness Scale

Please select your chance of dozing in the following situations:
Sitting and Reading:  Required
Watching TV:  Required
Sitting, inactive in a public place (e.g. a theatre or a meeting):  Required
As a passenger in a car for an hour without a break:  Required
Lying down to rest in the afternoon when circumstances permit:  Required
Sitting and talking to someone:  Required
Sitting quietly after lunch without alcohol:  Required
In a car, while stopped for a few minutes in traffic:  Required

Berlin Questionnaire

Your snoring is:  Required
Has your snoring ever bothered other people?  Required
How often do you snore?  Required
Has anyone noticed that you quit breathing during your sleep?  Required
How often do you feel tired or fatigued after your sleep?  Required
During your waking time, do you feel tired, fatigued or not ‘up to par’?  Required
Have you ever nodded of or fallen asleep while driving a vehicle?  Required

Other Risk Factors

Do you have high blood pressure (includes all people on treatment for blood pressure)?  Required
Confirmation  Required

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