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reception@swcpc.com.au
Suite 2.12, 90 Podium Way, Oran Park New South Wales 2570, Australia
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Our Team
Dr Saurabh Gupta
Dr Haider Naqvi
Dr Sherwin Amirmalek
Dr Michelle Donegan
Shondell Tilden
Services
Respiratory
Respiratory Function Testing
Sleep
Home-Based Sleep Studies
Mandibular Advancement Splint (MAS) Consultation
Information
Patients Resources
Practitioner Resources
Contact Us
Menu
Home
Our Team
Dr Saurabh Gupta
Dr Haider Naqvi
Dr Sherwin Amirmalek
Dr Michelle Donegan
Shondell Tilden
Services
Respiratory
Respiratory Function Testing
Sleep
Home-Based Sleep Studies
Mandibular Advancement Splint (MAS) Consultation
Information
Patients Resources
Practitioner Resources
Contact Us
Request a call
(02) 4607 5010
Pre-Sleep Patient Questionnaire
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Please enable JavaScript in your browser to complete this form.
Pre-Sleep Patient Questionnaire
To be answered the night of your sleep test and will be assessed by the sleep physician.
Patient Name
*
Date of Study
Patient Chart No.
What time did you go to bed last night?
Circle One
AM
PM
How long did it take you to fall asleep last night?
(minutes)
How many hours of sleep did you get last night?
(hours)
What time did you get up today?
Circle One (copy)
AM
PM
During the day today, did you...
Take any naps?
Yes
No
If yes, please explain
What time? AM/ PM
How Long?
(minutes)
Drink any Coffee, Tea or Cola?
Yes
No
If yes, please explain
What, how much, and what time?
10. did night?
Drink any alcohol?
Yes
No
If yes, please explain
What, how much, and what time?
Take any medications?
Yes
No
If yes, please explain
What, how much, and what time?
What for?
Did you do anything physically strenuous?
Yes
No
If yes, please explain
What, what time (AM/PM)?
Did you have anything unusual happen?
Yes
No
If yes, please explain
What, what time (AM/PM)?
Post-Sleep Questionnaire
To be answered the morning after your sleep test and will be assessed by the sleep physician.
Patient Name
*
Date of Study
Patient Chart No.
1. How long did it take you to get to sleep last night?
(minutes)
2. Did you wake up during the night?
Yes
No
If yes, how many times did you wake up last night?
(times)
If yes, what woke you up?
3. How many hours of sleep did you get last night?
(hours)
4. How well did you sleep last night? (Please check one)
Much worse
Worse
About the same
Better
Much Better
Please use the following scale to answer questions 5 through 8
1= Not at all
2= Somewhat
3= Average
4= Very
5= Extremely
5. How refreshing was your sleep last night?
6. How restless was your sleep last night?
7. How difficult was it to fall asleep last night?
8. How rested do you feel this morning?
9. Please place a mark on the scale below which describes your sleepiness right now
(1 - Very Sleepy || 10 - Completely Awake)
10. Is there anything else about the sleep study you would like to mention regarding your sleep?
Submit
Southwest Pulminary & Sleep Centre
4.8
Based on 4 reviews
Southwest Pulminary & Sleep Centre
4.8
review us on
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Toni Maree Cook
1677452837
Fabulous Drs and staff, so friendly I was made to feel at ease.
Harvinder Singh
1664153935
Dr Haider spends good amount of time with the patients and explains everything properly.
Indy Darmanin
1659668247
DINESH GOYAL
1642504811
I got the treatment very nice and dr were also very friendly and good behaviour. There charges are also very nice.
