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Initial Screening Assessment

The following screening questionnaire is designed to assess your sleep breathing symptoms and risk factors.

It can be useful in conjunction with a home sleep test or as a pre-test or pre-treatment screening.

After submitting your answers our team will contact you by phone to explain your options for further assessment or treatment.

Please enable JavaScript in your browser to complete this form.

1. Patient Information

Please indicate if any of the following applies to you, giving further details if necessary:

2. Your Sleep Problem

Please indicate if any of the following applies to you, giving further details if required:

I snore most nights
My snoring disturbs others
I sometimes have headaches when I wake up
I need to go to the bathroom frequently during the night
I have a previous diagnosis of OSA or other sleep disorder.
I have previously tried treatments for snoring or OSA e.g. CPAP, lifestyle change, etc

3. OSA Risk Assesment

Please answer each question below and record the total number of YES answers in the space provided. The score will give an indication of OSA risk.

(S) Are you a loud snorer (loud enough to be heard in another room)?
(T) Do you often feel tired, fatigued, or sleepy during the daytime?
(O) Has anyone seen you stop breathing or gasp for air during sleep
(P) Do you have high blood pressure?
(B) Is your body mass index more than 35?
If you don't know your BMI you can click here to use a free calculator.
(A) Are you over 50 years old?
(N) Is your neck/collar size more than 16 inches?
(G) Are you male?

4. Assessment of Daytime Sleepiness

Please indicate how likely are you to doze off or fall asleep in the following situations, 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 these things recently, try to work out how they would have affected you. Use the following scale to choose the most appropriate number for each situation.

Sitting & Reading
Sitting inactive in a public place - for example a theatre or meeting
Lying down to rest in the afternoon
Sitting quietly after lunch (when you've had no alcohol)
Watching Television
As a passenger in a car for an hour without a break
Sitting and talking to someone
In a car while stopped in traffic

5. Relevant Medical History

Please indicate whether you have suffered with any of these conditions personally or have any family history. Please provide further details when the answer is yes and if any personal conditions are well controlled.

Heart problems
High blood pressure
Diabetes
Thyroid syndrome
Stroke
Epilepsy
Acid reflux disease

6. Medications, Alcohol and Smoking