Waterloo Post-Sleep Questionnaire

Owen Sound Post-Sleep Questionnaire

For Owen Sound AccqSleepLabs patients, please fill out after your sleep study is complete.
1) Full Name*

First NameLast Name
2) Date of Birth
Day: *
Month: *
Year: *
3) Health Card #: * VC: *
4) How would you rate your sleep last night?*

ExcellentGoodFairPoor
5) How long do you estimate it took you to fall asleep last night?
Hours (number only): *
Minutes (number only): *
6) Did you wake up during the night?*

Yes *No
* If yes, how many times?
* If yes to waking up during the night, reason:

Need to urinateEquipment uncomfortableEquipment noiseAnxietyTensionFear of testDreams/Nightmares
* If dreams/nightmares or other, please explain:
7) Estimate your total sleep time
Hours (number only): *
Minutes (number only): *
8) How did you feel upon wakening?*

Alert/awake/energeticFunctioning at a high level/ able to concentrateFoggy/ DrowsyNot alertSleepy/ Woozy/ want to return to bedCannot stay awake
9) Overall, was last night’s sleep similar to your normal sleep at home?*

YesNo *
* If no, please explain:
10) Did you have trouble adjusting to the sleep lab setting / equipment?*

Yes *No
* If yes, please explain:
11) Do you feel that you were provided with enough information at the time of booking your sleep study?*

YesNo
12) Did the technical staff explain testing procedures clearly?*

YesNo
13) Were the technical staff attentive to your general needs while at the sleep laboratory?*

YesNo
14) How would you rate your overall experience in the sleep laboratory?*

ExcellentGoodFairPoor
15) Do you have any additional comments/ suggestions you would like to share with us?
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Owen Sound Post-Sleep Questionnaire