Please fill out the following questionnaire on sleep behaviour. The more questions you answer, the more accurate your results will be.
The questionnaire should take less than 5 minutes to answer, but please take your time and accurately complete the questionnaire.
Once the questionnaire is completed click the “submit” button at the bottom of the final page. If you exit the program before clicking the “submit” button no answers will be recorded or results presented. Also refrain from using the web-browser's "Back" button; if you require to return to previous questions please use the “previous” button at the bottom of the page. Use of the web-browser's "refresh" button will also clear any answers you have already entered.
Information collected through this form is for the sole use of David Nolte in relation to the individual concerned and holds only such personal information as is reasonable for us to deliver services to our patients. All information received will be kept confidential in accordance with the Privacy Act 1988 of the Commonwealth of Australia.
Section 1
Section 2
Usual time to bed:
Usual time of waking for day:
Employment status:
Personal G.P. Details:
Tick for permission for a David Nolte Pharmacist to contact your G.P. to discuss questionnaire results.
Section 5
How likely are you to fall asleep in the following situations? Even if you have not done theses things recently, try to work out how they have affected you.
Use the following scale to choose the most appropriate number for each situation.
0 = would never doze
1 = Slight chance of dozing
2 = Moderate chance of dozing
3 = High chance of dozing
Situation
Chance of Dozing
Sitting and reading
0
1
2
3
Watching television
0
1
2
3
Sitting inactive in a public place
0
1
2
3
As a car passenger for one hour
0
1
2
3
Lying down to rest in the afternoon
0
1
2
3
Sitting and talking to someone
0
1
2
3
Sitting quietly after lunch (without alcohol)
0
1
2
3
In a car, while stopped for a few minutes in traffic
If you snore, is your snoring is?
Slightly louder than breathing
As loud as talking
Louder than talking
Very Loud. Can be heard in adjacent rooms.
How often do you snore?
Nearly everyday
3-4 times a week
1-2 times a week
1-2 times a month
Never or nearly never
Does your snoring bother other people?
Yes
No
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
Section 7 How often do you feel tired or fatigued after waking from your sleep?
Nearly every day
3-4 times a week
1-2 times a week
1-2 times a month
Never or nearly never
During your waketime, 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
Have you ever nodded off or fallen asleep while driving a vehicle?
Yes
No
How often have you fallen asleep while driving a vehicle?
Nearly every day
3-4 times a week
1-2 times a week
1-2 times a month
Never or nearly never