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Sleep service assessment questionnaire

Online questionnaire for patients to complete before their assessment with the sleep service.

During the assessment with the sleep team assessor they will help with any questions that you are unsure about. If you need help at any time, please ask a member of the sleep team.

Sleep service assessment questionnaire

Type of sleep problem: What is the reason for this appointment?
Other medical problems
Please write them here or give a full list to the sleep assessor at your appointment

Sleep history

Do you snore?
Has anyone witnessed that you stop breathing or go quiet during sleep?
Has anyone witnessed that you stop breathing or go quiet during sleep?
Do you wake with a choking sensation?
Does anyone in your family have sleep apnoea?
Do you wake up most mornings with a headache?
Do you wake during the night?
Do you wake to go to the toilet?
Do you often feel fatigued, tired or sleepy during the daytime?
Do you wake feeling refreshed?
Do you usually nap during the day?

Social considerations

Average daily alcohol intake
Average daily caffeine intake. For example tea, coffee or energy drinks)
Smoking status

Occupation

Driving

Do you have a current driver's licence?
If yes, do you hold an HGV/PSV or other commercial license?
Have you ever felt sleepy while driving?
Have you ever had a sleep related incident or accident?
Do you drive as part of your occupation?
Do you operate heavy machinery or have a safety critical role/job?
Please confirm that you have received advice regarding the DVLA guidelines including advice that you must not drive if feeling sleepy

Restless legs

Do you have any pain that disturbs your sleep?
Do you get “restless legs”
If you have answered yes, please complete answer the following: When you sit or lie down do you have a strong desire to move your legs?
Does your desire to move your legs feel impossible to resist?
Could you describe the sensation as
Does moving your legs make them feel better?
Are these symptoms worse at night?
Does your partner ever report you have twitching legs at night?
Have you ever had any 'abnormal' nighttime behaviour? For example sleepwalking, sleep talking, abnormal movements, nightmares or acting out your dreams

Epworth sleepiness scale

How likely are you to doze off or fall asleep in the situations described below, in contrast to feeling tired? This refers to your usual way of life in recent times. Even if you haven’t done some of these things recently, please try to work out how they would have affected you. Please answer the last question as if you were a driver if you drive and as a passenger if you are a non-driver. Use the following scale to choose the most appropriate number for each situation: 0 = would never doze 1 = Slight chance of dozing 2 = Moderate chance of dozing 3 = High chance of dozing
Chance of dozing
Chance of dozing
Chance of dozing
Chance of dozing
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