Sleep New Patient Questionnaire

Patient Questionnaire

Contact Information

First Name *

Surname *

Email *

Date of birth *

Occupation

Usual GP *

Are you involved in providing emergency services or healthcare? *

YesNo

Does this occupation require you to operate a vehicle or heavy machinery? *

YesNo

Emergency Contact Name *

Emergency Contact Number *

Weight (kg)

Height (cm)

Sleep History

What time do you go to bed? *

How much sleep do you usually get? *

How often do you need to urinate overnight? *

Do you snore? *

YesNo

Do you stop breathing at night? *

YesNo

Do you wake with a dry mouth/throat? *

YesNo

Do you have trouble staying asleep? *

YesNo

Do you have significantly fragmented sleep? *

YesNo

Do you usually feel tired during the day? *

YesNo

Please describe your sleepNote: Include any problems, or factors interrupting your sleep (e.g. nasal congestion)

Epworth Sleepiness Scale (ESS): How often are you dozing or falling asleep during the following situations, in contrast to just feeling tired? This refers to our usual way of life in recent times.

If you haven't done some of these activities recently, please work out how they would have affected you.

Please read each statement on the scale and mark a number 0, 1, 2 or 3 which indicates how much the statement applied to you during the past week. There are no right or wrong answers. Do not spend too much time on any statement.

It is important to complete this for EVERY question.

The rating scale is as follows:

0 You would never doze off

1 There is a slight chance of dozing

2 There is a moderate chance of dozing

3 There is a high chance of dozing

ESS Total Score

Medical History

Any further details or conditions not listed above?Note: If applicable, please provide detail of any known cause for chronic pain or headaches.

Do you have any known allergies?

Smoking history (number per day, duration)

Alcohol intake (number per day/ week/ month)

Daily Caffeine Intake *

Medications

Medication (prescribed/ non-prescribed currently being taken)

Dosage (include if taken in morning or evening)

Are you having a consult with Dr Andrew Scott? *

YesNo

Have you ever had a previous sleep study done?

YesNo

Where and where did you have the test(s) done?

Have you been hospitalised in the last 2 years? *

YesNo

Provide more details eg treating doctor, investigations, treatment required. Please provide a discharge summary if available. *

Have you had any imaging of your chest and/or sinuses in the last 5 years?

YesNo

Example: X-rays, CT scans, MRI

Have you had any additional tests performed in the last 5 years?

YesNo

Example: MRI scans, ultrasound, bone density, ECG, echo, stress test

Please provide the name of the provider and date(s) performed.

Have you had blood test(s) done in the last 2 years?

YesNo

Have you had any of the following pathology tests done in the last 2 years?

SputumNasal swabsNo

Please provide name of provider and date(s) performedProvider example: Sullivan Nicolaides, QML, 4Cyte, GP

Have you seen other Specialists in the last 5 years?

YesNo

Provide details (Doctors name, location, date last seen)

Save and Complete Later

This form will be submitted via email to Thoracic and Sleep Group Queensland. A copy will also be sent to the email address provided above.