Download questionnaire about respiratory disorders during sleep

PULMOLOŠKA IN INTERNISTIČNA AMBULANTA SLOVENJ GRADEC
LABORATORY FOR SLEEP DISORDERS
Partizanska pot 16, 2380 Slovenj Gradec
Ordering: 00 386 59 255 000 ali 00 386 51 623 588 ali [email protected]
Information about services: www.pulmolog.com
QUESTIONNAIRE ABOUT RESPIRATORY DISORDERS DURING SLEEP
NAME AND SURNAME :
BIRTH DATE :
ESS questionnaire is used for determine the degree of excessive daytime sleepiness.
Result of more than 10 points ranks among drowsy and the result more than 18 points among very
sleepy.
Reached number 10 points or more should initiate reflection about insufficient amount of sleep,
improving sleep hygiene and consulting a professional.
INSTRUCTION: in solving the questionnaire please circle the appropriate response:
0 - NEVER: when you never nap or sleep in offered situation
1 - SMALL PROBABILITY: small probability to nap or sleep in offered situation
2 - MODERATE PROBABILITY: moderate probability to nap or sleep in offered situation
3 - HIGH PROBABILITY: high probability to nap or sleep in offered situation
SEATING AND READING
0
1
2
3
WATCHING TELEVISION
0
1
2
3
SEATING WITHOUT RESPONSIBILITY AT A PUBLIC PLACE
0
1
2
3
AS PASSENGER IN VEHICLE FOR 1 HOUR OR MORE
0
1
2
3
LAYING DOWN IN THE AFTERNOON
0
1
2
3
SEATING AND TALKING WITH ANOTHER PERSON
0
1
2
3
SEATING IN SILENCE AFTER LUNCH (WITHOUT ALCOHOL)
0
1
2
3
AS DRIVER IN TRAFFIC JAM THAT LASTS FOR FEW MINUTES
0
1
2
3
TOTAL NUMBER OF COLLECTED POINTS:
Circle the correct answer to the following supplementary questions:
Do you snore?
Are you tired after sleeping? Do you have to use the toilet at night?
Never
Never
Never
1-2 time per month
1-2 time per month
Exceptionally
1-2 time per week
1-2 time per week
Every night once
3-4 time per week
3-4 time per week
Every night twice
Every night
Every morning
Every night three times or more
How many years do you snore?_______years
How many hours do you sleep at night?
-during the week____hours
-at weekend___ hours
How many hours would you like to sleep? during the week____hours
-at weekend___ hours
Do you still feel sleepy during the day when you have the opportunity to sleep longer? YES NO