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Address: 121 King St, Dameitta, Egypt
Phone: +25-506-345-72
Email: motivoweb@gmail.com

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Sleep Questionnaire

The Epworth Sleepiness Scale helps you determine if you possibly suffer from a sleep disorder and its severity. This scale was developed in 1991 by Dr. Murray Johns right here in Melbourne.

Our sleep questionnaire assesses your sleepiness along with some common risks and symptoms to determine your likelihood of a sleep related issue. Complete the questionnaire now and find out if you require a diagnostic sleep study.

Please complete all required fields!

How likely are you to doze off or fall asleep:
Sitting and Reading?*

How likely are you to doze off or fall asleep:
Watching TV?*

How likely are you to doze off or fall asleep:
Sitting, inactive in a public place? (e.g. a theatre or a meeting)*

How likely are you to doze off or fall asleep:
As a passenger in a car for an hour without a break?*

How likely are you to doze off or fall asleep:
Lying down to rest in the afternoon when circumstances permit?*

How likely are you to doze off or fall asleep:
Sitting and talking to someone?*

How likely are you to doze off or fall asleep:
Sitting quietly after a lunch without alcohol?*

How likely are you to doze off or fall asleep:
In a car, while stopped for a few minutes in the traffic?*

Is your waist circumference greater than
102cm (male) or 88cm (female) at the belly button?*

Has your snoring ever bothered other people?*

Has anyone noticed that you stop breathing during your sleep?*

Are you aged 50 or over?*

Your Sleep Result

Epworth
Sleepiness Scale
0/24

OSA-50 Sleep Apnea
Risk Screening
0/10

*Based on your results of these sleep assessments you may wish to e-mail your results of the tests to discuss with your doctor for a possible referral for a sleep study.
Continue
Email Address*
Please enter your email address

Sleep Test Enquiry

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Enquiries

  • 03 9908 5800
  • 1300 466 375
  • 03 9012 4156
  • bookings@homesleep.com.au

Working Hours

Home Sleep Melbourne

Mon – Fri: 10 am to 5 pm

Home Sleep Cheltenham

Mon – Fri: 10 am to 5 pm

Home Sleep Seymour

Mon – Thu: 10 am to 5 pm

Contact Us

Home Sleep Studies Australia
Suite 502, 12-14 Claremont Street, South Yarra VIC 3141

Suite 11, 1253 Nepean Hwy, Cheltenham VIC 3192

92 Station Street, Seymour, VIC 3660

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Contact Us
Refer patient

Find us on Health Link and Medical objects to refer your patients

or

Download to refer your patient for a sleep study.

  • Download the referral form
  • Fill out the patient’s information
  • Email the form to: bookings@homesleep.com.au or
    fax to 03 9012 4156
  • Our report will be delivered within one week

Referral Form

Enquiry Now

Bringing the latest scientific approach to help Australians solve their sleep problems



    Send Sleep Enquire