<div style="text-align: center;"> <div style="padding-bottom: 5px;"> </div> <div style="padding-bottom: 5px;"> </div> <div style="padding-bottom: 5px;"><img class="img-auto" style="min-width: 100px; max-width: 4448px;" src="https://www.quiz-maker.com/3012/CDN/91-4446681/wellvana-sleep.png" alt="Wellvana Sleep" width="201" height="66" /></div> <div style="padding-bottom: 5px;"> </div> <div style="padding-bottom: 5px;"><span style="font-size: 36pt; color: #2c8081;">Sleep Questionnaire</span></div> </div>

Do you suspect you may be suffering from sleep apnoea?

Check your sleep or start the discussion with your doctor through this survey.

To qualify for Medicare benefits you must reach a certain score on at least 2 of 3 approved questionnaires.

To fast-track this process, you can complete these questionnaires here, and download the results to give to your doctor.

Regardless of the results, Wellvana Sleep can offer you support and services.

This form includes 2 questionnaires and will take approx. 3 mins to complete.

Questionnaire 1:

Epworth Sleepiness Scale

Questionnaire 1:

Epworth Sleepiness Scale

How likely are you to doze off or fall asleep in the following situations?

Sitting and reading:

Never

Slight

Moderate

High

Watching television:

Never

Slight

Moderate

High

Sitting inactive in a public place (e.g. Theatre or meeting):

Never

Slight

Moderate

High

As a passenger in a car for an hour without a break:

Never

Slight

Moderate

High

Lying down to rest in the afternoon when circumstances permit:

Never

Slight

Moderate

High

Sitting and talking to someone:

Never

Slight

Moderate

High

Sitting quietly after lunch without alcohol:

Never

Slight

Moderate

High

In a car as a driver stopped for a few minuets in traffic:

Never

Slight

Moderate

High

Questionnaire 2:

STOP-BANG

Questionnaire 2:

STOP-BANG

Do you snore loudly? Louder than talking or loud enough to be heard through closed doors?

Yes

Do you often feel tired, fatigued, or sleepy during the daytime?

Yes

Has anyone observed you stop breathing or choking/gasping during sleep?

Yes

Do you have (or are you being treated for) high blood pressure?

Yes

Do you have a BMI over 35 kg/m2?

Yes

Unknown (will be scored as 'no')

Are you older than 50 years of age?

Yes

Do you have a neck circumference* over 43 cm (male) / 41 cm (female)?

* Measured around Adams Apple

Yes

Unknown (will be scored as 'no')

Is your sex male?

Yes

What is your email address?

Sleep Questionnaire

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