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Conditions We Treat
Respiratory Disorders
Lung Cancer
Pleural Disorders
Interstitial Lung Disease
Obstructive Sleep Apnoea & Sleep Disorders
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Interventional Bronchoscopy
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Pulmonary Function Testing
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Preparing for Home Sleep Studies
Sleep Study Questionnaire
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Sleep Study Questionnaire
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Step 1: Personal Information
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Invalid Date Format
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Sex
Male
Female
Please Select Gender
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Email Format Incorrect
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Interpreter Required
Yes
No
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EPWORTH SLEEPINESS SCALE (SCORE 8 OR MORE TO PROCEED)
Choose the most appropriate value for each situation
Sitting and reading
Would never doze
Slight chance of dozing
Moderate chance of dozing
High chance
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Watching television
Would never doze
Slight chance of dozing
Moderate chance of dozing
High chance
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Sitting inactive in a public place ( e.g. a theatre or meeting )
Would never doze
Slight chance of dozing
Moderate chance of dozing
High chance
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As a passenger in a car for an hour without a break
Would never doze
Slight chance of dozing
Moderate chance of dozing
High chance
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Lying down to rest in the afternoon when circumstances permit
Would never doze
Slight chance of dozing
Moderate chance of dozing
High chance
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Sitting and talking to someone
Would never doze
Slight chance of dozing
Moderate chance of dozing
High chance
This Field Required
Sitting quietly after lunch without alcohol
Would never doze
Slight chance of dozing
Moderate chance of dozing
High chance
This Field Required
In a car, while stopped for a few minutes in traffic
Would never doze
Slight chance of dozing
Moderate chance of dozing
High chance
This Field is Required
STOP BANG SLEEP APNEA QUESTIONNAIRES (SCORE 3 OR MORE TO PROCEED)
Do you snore loudly?
Yes
No
This Field is Required
Do you often feel tired?
Yes
No
This Field is Required
Has anyone observed you stop breathing?
Yes
No
This Field is Required
Do you have or are you being treated for high blood Pressure?
Yes
No
This Field is Required
Neck circumfrence more than 40cm/ 16 inches?
Yes
No
This Field is Required
OSA 50 SCREENING QUESTIONNAIRE (SCORE 5 OR MORE TO PROCEED)
This Field is Required
Has your snoring ever bothered other people
Yes
No
This Field is Required
Has anyone noticed that you stop breathing during your sleep?
Yes
No
This Field is Required
BERLIN QUESTIONNAIRE (SCORE POSITIVE IN 2 OR MORE CATEGORIES TO PROCEED)
This is the last set of questions and it’s multiple choice. Please choose one.
Category 1
Do you snore?
Yes
No
Dont Know
This Field is Required
How loud is your snoring?
Slightly louder than breathing
As loud as talking
Louder than talking
Very loud – can be heard in adjacent Rooms
This Field is Required
How often do you snore?
Nearly every day
3-4 times a week
1-2 times a week
1-2 times a month
Never or nearly never
This Field is Required
Has your snoring ever bothered other people?
Yes
No
Dont Know
This Field is Required
Has anyone noticed that you quit breathing during your sleep?
Nearly every day
3-4 times a week
1-2 times a week
1-2 times a month
Never or nearly never
This Field is Required
Category 2
How often do you feel tired or fatigued after your sleep
Nearly every day
3-4 times a week
1-2 times a week
1-2 times a month
Never or nearly never
This Field is Required
During your waking time, do you feel tired, fatigued or not up to par?
Nearly every day
3-4 times a week
1-2 times a week
1-2 times a month
Never or nearly never
This Field is Required
Have you ever nodded off or fallen asleep while driving a vehicle?
Yes
No
This Field is Required
Category 3
Do you have high blood pressure?
Yes
No
Dont Know
This Field is Required
