Home
Meet Dr Goldin
Information for Doctors
Information for Doctors
PDF Referral Form
Our Services
Information For Patients
Information For Patients
PDF Referral Form
FAQ'S
Dr Goldin's Sleep Tips
Dr Goldin's Sleep Tips
5 Key Requirements When Selecting A Sleep Service
5 TIPS FOR STARTING CPAP
Sleep Disorders
Contact
Home
Meet Dr Goldin
Information for Doctors
PDF Referral Form
Our Services
Information For Patients
PDF Referral Form
FAQ'S
Dr Goldin's Sleep Tips
5 Key Requirements When Selecting A Sleep Service
5 TIPS FOR STARTING CPAP
Sleep Disorders
Contact
Stop Bang & Epworth Sleepiness Form
Screening questionnaire for obstructive sleep apnoea
Patient Name *
Contact phone number *
Email address *
Referring Doctor *
Height (cm) *
Weight (kg) *
Age *
Gender
Please select
Male
Female
BMI
1. Snoring
Do you snore loudly (louder than talking or loud enough to be heard through closed doors)?
Please select
Yes
No
2. Tired
Do you often feel tired, fatigued, or sleepy during daytime?
Please select
Yes
No
3. Observed
Has anyone observed you stop breathing during your sleep?
Please select
Yes
No
4. Blood Pressure
Do you have or are you being treated for high blood pressure?
Please select
Yes
No
5. BMI
Is your BMI more than 35 kg/m2? (if unsure please leave black)
Please select
Yes
No
6. Age
Are you over 50 years old?
Please select
Yes
No
7. Neck Circumference
Is your neck circumference greater than 40 cm?
Please select
Yes
No
8. Gender
Are you male?
Please select
Yes
No
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.
Situation Chance of dozing
Sitting and reading
Please select
Would never doze
Slight chance of dozing
Moderate chance of dozing
High chance of dozing
Watching TV
Please select
Would never doze
Slight chance of dozing
Moderate chance of dozing
High chance of dozing
Sitting, inactive in a public place (eg. a theatre or a meeting)
Please select
Would never doze
Slight chance of dozing
Moderate chance of dozing
High chance of dozing
As a passenger in a car for an hour without a break
Please select
Would never doze
Slight chance of dozing
Moderate chance of dozing
High chance of dozing
Lying down to rest in the afternoon when circumstances permit
Please select
Would never doze
Slight chance of dozing
Moderate chance of dozing
High chance of dozing
Sitting and talking to someone
Please select
Would never doze
Slight chance of dozing
Moderate chance of dozing
High chance of dozing
Sitting quietly after a lunch without alcohol
Please select
Would never doze
Slight chance of dozing
Moderate chance of dozing
High chance of dozing
In a car, as the driver, while stopped for a few minutes in traffic
Please select
Would never doze
Slight chance of dozing
Moderate chance of dozing
High chance of dozing
Additional Comments
* Required fields