Morning Questionnaire
Patient Given Name (as per Medicare card)
*
Patient Surname (as per Medicare Card)
*
DOB
*
Phone
*
Address
Medicare
Ref
Exp
Referring Doctor
Normal GP (if different to referring GP)
Date of study
*
What time did you go to bed last night?
How long did it take you to fall asleep?
What time did you wake up in the morning?
What time did you get out of bed?
How did you sleep compared to normal?
What positions do you recall sleeping in?
What medications and supplements have you taken in the past 24 hours?
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If the study meets the criteria, I give permission for the sleep study data to be reported and the service billed under Medicare item number 12250
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Any other notes for the Sleep scientist/Doctor
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