Tīpoka ki te ihirangi
3 Night Sleep Study Questionnaire
3 Night Home Sleep Study Questionnaire
Patient Details
Full Name:
Email Address:
Date of Birth:
Height (cm):
Weight (kg):
Neck circumference (cm):
BMI (kg/m²):
Gender:
Select...
Male
Female
Other
STOP-BANG Questionnaire
1. Do you snore loudly?
Yes
No
2. Do you often feel tired, fatigued, or sleepy during the daytime?
Yes
No
3. Has anyone observed you stop breathing or choking/gasping during your sleep?
Yes
No
4. Do you have or are being treated for high blood pressure?
Yes
No
5. Is your Body Mass Index more than 35 kg/m²?
Yes
No
(Determined automatically from your height and weight)
6. Are you over 50 years old?
Yes
No
(Determined automatically from your date of birth)
7. Is your neck circumference greater than 40 cm?
Yes
No
8. Are you male?
Yes
No
(Determined automatically from your gender selection)
Epworth Sleepiness Scale (ESS)
How likely are you to doze off or fall asleep in the following situations?
1. Sitting and reading:
0
1
2
3
2. Watching TV:
0
1
2
3
3. Sitting inactive in a public place:
0
1
2
3
4. As a passenger in a car for an hour without a break:
0
1
2
3
5. Lying down to rest in the afternoon:
0
1
2
3
6. Sitting and talking to someone:
0
1
2
3
7. Sitting quietly after lunch (without alcohol):
0
1
2
3
8. In a car, while stopped for a few minutes in traffic:
0
1
2
3
Do you have any heart conditions, particularly heart failure, atrial fibrillation, or history of stroke?
Yes
No
Do you take opioid medications (prescription pain medications) regularly?
Yes
No
Have you ever had a brain injury, brain tumor, or neurological disorder?
Yes
No
Do you have any respiratory conditions such as COPD or chronic respiratory failure?
Yes
No
Have you ever been diagnosed with Cheyne-Stokes breathing pattern?
Yes
No
Has anyone observed pauses in your breathing during sleep that don't appear to be associated with snoring or gasping?
Yes
No
Do you wake up feeling short of breath or gasping for air?
Yes
No
Do you experience insomnia, particularly difficulty staying asleep?
Yes
No
Do you live at high altitude or have you recently moved to a higher altitude?
Yes
No
Have you previously been treated with CPAP for sleep apnea? If yes, did you experience a feeling of air hunger or difficulty exhaling against the pressure?
Yes
No
Medical History
Please list any diagnosed medical conditions and all medications/supplements you currently take:
Do you have a family history of sleep disorders or have you previously been diagnosed with a sleep disorder or had a sleep study?
Sleep Patterns
What is your primary sleep complaint and how long have you experienced it? Did anything significant happen when these problems began?
On a typical night:
What time do you get into bed and try to fall asleep?
How long does it take you to fall asleep? (minutes)
How many times do you wake up and for how long total? (minutes)
What time do you finally wake up and get out of bed?
Do you feel refreshed upon awakening?
Yes
No
Sometimes
Sleep Environment & Lifestyle
Describe your sleep environment (who you share with, noise level, comfort) and bedtime routine:
Do you use electronic devices in bed before sleeping?
Yes
No
Sometimes
How would you rate your general fitness?
Select...
Excellent
Good
Average
Poor
How often do you exercise?
Select...
Daily
Several times a week
Once a week
Rarely
Never
What type(s) of exercise do you do? (e.g. walking, running, gym, sports, yoga, etc.)
Please describe your consumption habits (caffeine, alcohol, nicotine):
What is your occupation and work schedule? Do you work shifts?
Additional Symptoms
Do you experience any of the following? (Check all that apply)
Unpleasant sensations in legs that improve with movement
Muscle weakness during strong emotions
Teeth grinding, sleepwalking, or unusual sleep behaviors
Heartburn or reflux during sleep
Morning headaches
Difficulty concentrating during the day
Irritability or mood changes
Falling asleep unintentionally during the day
Dry mouth or sore throat upon waking
Frequent urination at night
Restless sleep or frequent tossing and turning
Other:
Submit Questionnaire
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