Sleep Apnoea Questionnaire

If you have been advised by the surgery to do so, please submit this form.

For more information about OSAHS:

Our website should not to be used to request medication.

Sleep Apnoea Questionnaire

Section

Epworth Sleepiness Scale

Please select your chance of dozing in the following situations:

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

Berlin Questionnaire

Category 1: Your Snoring

Your snoring is: *
Has your snoring ever bothered other people? *
How often do you snore? *
Has anyone noticed that you quit breathing during your sleep? *

Category 2: Tiredness & Fatigue

How often do you feel tired or fatigued after your sleep? *
During your waking time, do you feel tired, fatigued or not ‘up to par’? *
Have you ever nodded of or fallen asleep while driving a vehicle? *
How often does this occur? *

Category 3: Other Risk Factors

Do you have high blood pressure (includes all people on treatment for blood pressure)? *
eg. 1.75
eg. 60.6
Please note: BMI calculator is only for patients aged 18 and over.
*