Unichem Rototuna Pharmacy

Welcome to the Sleep Apnoea Questionnaire

This questionnaire involves 16 questions to test if you may be at risk of Obstructive Sleep Apnoea, the approximate time is around 5 minutes.

Begin

Sleep Apnoea Questionnaire

1/16

Snoring

Do you snore loudly (loud enough to be heard through closed doors)?

Sleep Apnoea Questionnaire

2/16

Prev Question

Tired

Do you often feel tired, fatigued, or sleepy during the daytime (falling asleep while driving or talking to someone)?

Sleep Apnoea Questionnaire

3/16

Prev Question

Observed

Has anyone observed you stop breathing or choking/gasping during your sleep?

Sleep Apnoea Questionnaire

4/16

Prev Question

Pressure

Do you have or are you being treated for high blood pressure?

Sleep Apnoea Questionnaire

5/16

Prev Question

Body Mass Index

Is your Body Mass Index (BMI) more than 35kg/m2 according to your height and weight?

Height(cm)

Weight(kg)

BMI-

Sleep Apnoea Questionnaire

6/16

Prev Question

Age

Are you older than 50?

Sleep Apnoea Questionnaire

7/16

Prev Question

Neck

Do you have a large sized neck?
For male, is your shirt collar 17 inches / 43 cm or larger?
For female, is your shirt collar 16 inches / 41cm or larger?
(measured around Adam’s apple)

Sleep Apnoea Questionnaire

8/16

Prev Question

Gender

Are you male?

Epworth Sleepiness Scale

9/16

Prev Question

Please answer the following questions on how likely you would be to doze off or fall asleep, while doing the following activities.

Sitting and reading :

Epworth Sleepiness Scale

10/16

Prev Question

Please answer the following questions on how likely you would be to doze off or fall asleep, while doing the following activities.

Watching television :

Epworth Sleepiness Scale

11/16

Prev Question

Please answer the following questions on how likely you would be to doze off or fall asleep, while doing the following activities.

Sitting inactive in a public place (e.g. a theatre/meeting):

Epworth Sleepiness Scale

12/16

Prev Question

Please answer the following questions on how likely you would be to doze off or fall asleep, while doing the following activities.

As a passenger in a car for an hour with no break:

Epworth Sleepiness Scale

13/16

Prev Question

Please answer the following questions on how likely you would be to doze off or fall asleep, while doing the following activities.

Lying down in the afternoon (when possible):

Epworth Sleepiness Scale

14/16

Prev Question

Please answer the following questions on how likely you would be to doze off or fall asleep, while doing the following activities.

Sitting and talking to someone:

Epworth Sleepiness Scale

15/16

Prev Question

Please answer the following questions on how likely you would be to doze off or fall asleep, while doing the following activities.

Sitting quietly after lunch without alcohol:

Epworth Sleepiness Scale

16/16

Prev Question

Please answer the following questions on how likely you would be to doze off or fall asleep, while doing the following activities.

In a car, while stopped for a few minutes in traffic: