Patient Consent and Detail Form

Patient Details

Health Information

Please indicate if you have:

If answered yes to any of the above, a specialist referral is required and a level 3 home sleep test is not suitable.

Sleep apnoea screening Epworth Sleepiness Scale

Please answer these questions on what chance, during the following situations, you are likely to doze off or fall asleep...

0 = never

1 = slight

2 = moderate

3 = high

Sleep apnoea screening STOP-Bang Questionnaire

Please answer the following questions to determine if you may be at risk of Obstructive Sleep Apnoea.

Doctor information