Patient General Questionnaire Please enable JavaScript in your browser to complete this form.Name *FirstLastDate of birth *Approximately what height would you be in metres? *Approximately what weight would you be in kilograms? *Please tick all of the symptoms that apply to you. (copy)Witnessed pauses in breathingSnoringGasping for air at nightRestless SleepRestless legs during the day and or legs twitching at nightUnrefreshed sleepMorning headachesImpaired ConcentrationPoor memoryDo you have any other underlying medical conditions e.g. asthma, COPD, depression etc?Are you currently on any of the following treatments for your breathing at night?CPAPNIVOxygenMandibular advancement device/dental deviceNone of the above treatmentsWhat medication are you taking? Do you work night shift? how many cups of tea or coffee would you consume on a daily basis?What licence do you currently hold?I don't driveCarHGVPSVDo you feel sleepy while driving?YesNoThird ChoiceDo you have a pacemaker?YesNoWhat time do you wake up at? What time do you normally go to bed at?Is there any other information you would like to include that you think might be relevant?Submit
