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Sleep and Snoring Questionnaires

ALL SECTIONS OF THIS FORM MUST BE COMPLETED, THANK YOU.

These questionnaires help Dr Crawford to understand if you meet the Medicare requirements for direct referral for a home sleep study, rather than having to be referred to Sleep Physician, and assess how much your snoring and sleep disturbance is impacting on your life.

Please answer all questions as best you can.

"*" indicates required fields

1Step 1 - Patient Information

2Step 2 - OSA 50 Screening Questionnaire

3Step 3 - Snoring Severity Scale

4Step 4 - FQSQ - 10

Full Name*

Date*

Your Age*

Gender*

Male

Female

Indeterminant

Your weight in kilograms*

Your height (cm)*

How likely are you to doze off or fall asleep in the situations described below, in contrast to feeling just tired? This refers to your usual way of life in recent times. Even if you have not done some of the things recently, try to work out how they would have affected you.

Situation

My chance of dozing whilst sitting and reading*

Would never doze	Slight chance of dozing	Moderate chance of dozing	High chance of dozing

My chance of dozing whilst watching TV*

Would never doze	Slight chance of dozing	Moderate chance of dozing	High chance of dozing

My chance of dozing whilst sitting, inactive in a public place ( e.g. a theatre or a meeting)*

Would never doze	Slight chance of dozing	Moderate chance of dozing	High chance of dozing

My chance of dozing 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 of dozing

My chance of dozing lying down to rest in the afternoon when circumstances permit*

Would never doze	Slight chance of dozing	Moderate chance of dozing	High chance of dozing

My chance of dozing whilst sitting and talking to someone*

Would never doze	Slight chance of dozing	Moderate chance of dozing	High chance of dozing

My chance of dozing sitting quietly after a lunch without alcohol*

Would never doze	Slight chance of dozing	Moderate chance of dozing	High chance of dozing

My chance of dozing in a car, while stopped for a few minutes in the traffic*

Would never doze	Slight chance of dozing	Moderate chance of dozing	High chance of dozing

OSA 50 SCREENING QUESTIONNAIRE

Overall weight*

Waist circumference: Male > 102cm or Females > 88cm

Yes

Snoring*

Has your snoring ever bothered other people?

Yes

Apneas*

Has anyone noticed that you stop breathing during your sleep?

Yes

Age*

Are you over 50 years old?

Yes

EXPERTISE, EXPERIENCE, EXCELLENCE

(02) 8319 9434

SNORING & OSA

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Sleep and Snoring Questionnaires

ALL SECTIONS OF THIS FORM MUST BE COMPLETED, THANK YOU.

Situation

OSA 50 SCREENING QUESTIONNAIRE

Snoring Severity Scale

Functional Outcome of Sleep Questionnaire

Instructions

Quick Links

Conditions & Treatments

Practice Information

Location

Dr Julia Crawford does not see adult patients for ear-related conditions and does not perform cosmetic nasal surgery.