Sleep Assessment This is a scientifically validated test to determine your eligibility for a Medicare subsidised sleep study.First Name* Email* Mobile*Gender* Male Female How likely are you to doze off in the following situations? 0 = No Change 3 = High ChangeHow likely are you to doze off sitting and reading?*Select oneNo ChanceSlight ChanceModerate ChanceHigh ChanceHow likely are you to doze off watching tv?*Select oneNo ChanceSlight ChanceModerate ChanceHigh ChanceHow likely are you to doze off in a public place eg meeting or theatre?*Select oneNo ChanceSlight ChanceModerate ChanceHigh ChanceHow likely are you to doze off as a passenger in a car for an hour without a break?*Select oneNo ChanceSlight ChanceModerate ChanceHigh ChanceHow likely are you to doze off lying down to rest in the afternoon?*Select oneNo ChanceSlight ChanceModerate ChanceHigh ChanceHow likely are you to doze off sitting and talking to someone?*Select oneNo ChanceSlight ChanceModerate ChanceHigh ChanceHow likely are you to doze off in a car while stopped for a few minutes in traffic?*Select oneNo ChanceSlight ChanceModerate ChanceHigh ChanceHow likely are you to doze off sitting quietly after lunch without alcohol?*Select oneNo ChanceSlight ChanceModerate ChanceHigh Chance STOP BANG QuestionnaireDo you snore loudly (loud enough to be heard through closed doors or your bed-partner elbows you for snoring at night)?* Yes No Do you often feel tired, fatigued, or sleepy during the day (such as falling asleep during driving or talking to someone)?* Yes No Has anyone observed you stop breathing or choking/gasping during your sleep?* Yes No Do you have or are you being treated for high blood pressure?* Yes No Is your body mass index more than 35 kg/m2?* Yes No Are you aged older than 50?* Yes No Is your neck size large: For male, is your shirt collar 17 inches / 43cm or larger? For female, is your shirt collar 16 inches / 41cm or larger? (Measured around adams apple)* Yes No Is your gender male?* Yes No PhoneThis field is for validation purposes and should be left unchanged. Make an appointment "*" indicates required fields First Name* Last Name* Phone*Email* Message*NameThis field is for validation purposes and should be left unchanged.
