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1
Basic Sleep Information
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2
Sleep Disturbances
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3
Sleep Apnea Risk Assessment
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4
Personal Information
Basic Sleep Information
Sleep Timing and Duration
The following questions relate to your usual sleep habits during the past month only. Your answers should indicate the most accurate reply for the majority of days and nights in the past month. Please answer all questions.
Sleep Disturbances
Factors Affecting Sleep Quality
Identify any issues or disturbances that affect your sleep quality, such as waking up during the night or
feeling unrested.
a) Cannot get to sleep within 30 minutes
b) Wake up in the middle of the night or early morning
c) Have to get up to use the bathroom
d) Cannot breathe comfortably
e) Cough or snore loudly
f) Feel too cold
g) Feel too hot
h) Had bad dreams
i) Have pain
j) Other reason(s), please describe:
How often during the past month have you had trouble sleeping because of this?
Sleep Apnea Risk Assessment
Sleep Apnea Risk Factors
Assess potential risk factors for sleep apnea, including symptoms like snoring, choking during sleep, and
daytime fatigue.
Calculated BMI (kg/m2)
0Personal Information
Personal Details and Sleep Profile
Enter your personal details and provide additional context about your sleep habits and health to help us
understand your sleep profile better.
Sleep Health Assessment Summary
Thank you for completing the questionnaire.
Subjective Sleep Health Status
SCORE
5
Poor sleep score = 5 or higher
Good sleep score = 4 or less
Sleep Apnea Risk Assessment
SCORE
4
High risk of sleep apnea score = 5-8
Intermediate risk of sleep apnea score = 3-4
Low risk of sleep apnea score = 0-2
