Sleep Assessment

First Name *

Last Name *

Date of Birth *

Phone Number *

Email Address *

Medicare Card Number

Expiry

Your Reference Number

Your Address

Street address

City

State

Postcode

Do you snore?

YesNo

Is It loud?

YesNo

Is It frequent?

YesNo

Has it disturbed others?

YesNo

Are you tired?

YesNo

In the morning 3+ days per week?

YesNo

Later in the day 3+ times per week?

YesNo

Have you ever nodded off whilst driving?

YesNo

Has anyone noted that you stop breathing during sleep?

YesNo

Does this happen 3+ times per week?

YesNo

Do you have high blood pressure?

YesNo

Are you medicated? If so, which medication do you use?

Height

Weight

BMI

Are you overweight? (BMI 30+)

YesNo

Is your waist measurement 88cm+ (female) or 102cm (Male)?

YesNo

Do you have a large neck?

YesNo

40cm or larger

Are you aged over 50?

YesNo

Are you a male?

YesNo

Do you have Diabetes?

YesNo

Have you had a Stroke/TIA?

YesNo

Have you had a Heart Attack?

YesNo

Do you have Heart Disease?

YesNo

What time have you been going to bed lately? *

What time have you been waking lately? *

How would you describe your recent sleep quality?

What about your sleep issues impacts you most?

If you have a GP referral or other relevant documents, upload here

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ESS

STOPBANG

OSA50

Berlin Shows a high risk if 2+ Sections positive

Berlin Section 1

Berlin Section 2

Berlin Section 3

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