Sleep Questionnaire – Melbourne Respiratory & Sleep Services

226 Burgundy Street
Heidelberg VIC 3084
Ph: 9459 0555
Fax: 9455 0786

MEDICARE REQUIRED QUESTIONNAIRE FOR DIRECT REFERRAL FOR SLEEP STUDIES (AT HOME OR IN LAB)

ESS ≥ 8 & OSA-50 ≥ 5 (Both conditions must be satisfied)

Epworth Sleepiness Scale (ESS)

Name

Date

Age (Years)

Sex

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 haven't done some of these things recently, try to work out how they would have affected you.

Use the following scale:
0 = Would never doze
1 = Slight chance of dozing
2 = Moderate chance of dozing
3 = High chance of dozing

Sitting and Reading

Watching TV

Sitting, inactive in a public place (e.g. theatre or a meeting)

As a passenger in a car for an hour without a break

Lying down to rest in the afternoon when circumstances permit

Sitting and talking to someone

Sitting quietly after lunch without alcohol

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

Johns MW. A new method for measuring daytime sleepiness: the Epworth sleepiness scale. Sleep. 1991 Dec;14(6):540-5.

OSA-50 Screening Questionnaire

Please answer the following questions. A score of 5 or above (out of 10) may indicate a risk of Obstructive Sleep Apnoea.

Obesity = Yes (3), No (0)
Snoring = Yes (3), No (0)
Apnoeas = Yes (2), No (0)
Age 50 or Over = Yes (2), No (0)

Obesity – Waist circumference: Male > 102 cm or Female > 88 cm

Snoring – Has your snoring ever bothered other people?

Apnoeas – Has anyone noticed that you stop breathing during your sleep?

Age – Are you aged 50 years or over?

CL Chai-Coetzer, et al. Thorax, 2011; 66: 213–219

Additional Comments

Please upload your referral here

Epworth Sleepiness Scale (ESS)

OSA-50 Screening Questionnaire

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