Sleep and Health Questionnare

Please complete our sleep and medical assessment as fully as possible. Any questions please give us a call on 01978 254422.
Name

PrefixFirst NameLast Name
Date of Birth

DayMonthYear
Todays Date

DayMonthYear
Date
Sex
Contact Number

Area CodePhone Number
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Necksize in centimeters
Your occupation
Does your occupation involve shift work?
Type of driving licence held
Do you feel sleepy when driving
Have you had any accidents or near-misses when driving
Have you had to pull over with sleepiness when driving
If answer is yes to any of the above questions please provide as much information as possible

Medication currently taking

Payment Options
If using health insurance please complete the details below.

Please note Vitality health will no longer cover sleep studies on a general basis. Patients can ask for it to be covered but must get special authorisation.
Insurance company name
Insurance company policy number
Insurance company authorisation or claim number
If using insurance please confirm that you have adequate cover for your treatment by obtaining a pre authorisation number. If invoice is not settled in full by your insurer, any outstanding costs to be met by the patient.*

Yes
Are you happy by completing this form you are giving Ventility Sleep Solutions consent to share your personal and medical details with external specialists (Sleep Physiologist and Respiratory Consultant).*

Yes
Are you happy to agree that if the supplied sleep study is not used or returned to Ventility Sleep Solutions within one month of delivery a charge of £100 will be incurred.*

Yes
Should be Empty:

	Yes	Sometimes	No
Sleepiness
Snoring
Unrefreshed Sleep
Do you feel rested when you wake up
Do you get discomfort/pins & needles/tingling down your legs at night
Do you have an irresistible urge to move your legs to ease the discomfort

	No Chance	Slight Chance	Moderate Chance	High Chance
Sitting and reading
Watching TV
Sitting inactive in a public place (like a theatre or a meeting)
Sitting as a passenger in a car for an hour without a break
Lying down to rest in the afternoon when circumstances permit
Sitting and talking to someone
Sitting quietly after lunch without alcohol
In a car, while stationary for a few minutes in traffic