Sleep Assessment Form
Please complete these questions to the best of your ability. The AI will calculate your score and send you the results. Additionally, a detailed PDF document explaining these results and provides educational information about what to do about sleep problems will be emailed to you. Your personal details will never be shared with anyone else, and you will not receive any spam from Vik Veer.
Please provide your Email address so the report and a PDF Document explaining the results can be sent to you.
*
STAMP Questionnaire
Please answer the questions below for your score
I have been sweating heavily at night.
*
Never
0
1
2
3
4
Always
5
0 is Never, 5 is Always
I wake up at night gasping or choking.
*
Never
0
1
2
3
4
Always
5
0 is Never, 5 is Always
I wake up at night to go to the toilet.
*
Never
0
1
2
3
4
Always
5
0 is Never, 5 is Always
I wake up with a headache in the mornings.
*
Never
0
1
2
3
4
Always
5
0 is Never, 5 is Always
I wake up with a dry or sore throat.
*
Never
0
1
2
3
4
Always
5
0 is Never, 5 is Always
I have had a reduced sexual drive.
*
Never
0
1
2
3
4
Always
5
0 is Never, 5 is Always
I am tired all the time.
*
Never
0
1
2
3
4
Always
5
0 is Never, 5 is Always
I wake up unrefreshed after a normal night’s sleep.
*
Never
0
1
2
3
4
Always
5
0 is Never, 5 is Always
If I have the opportunity, I would nap in the afternoons.
*
Never
0
1
2
3
4
Always
5
0 is Never, 5 is Always
I have trouble concentrating on tasks.
*
Never
0
1
2
3
4
Always
5
0 is Never, 5 is Always
I have to make extra effort to stay alert.
*
Never
0
1
2
3
4
Always
5
0 is Never, 5 is Always
I forget things.
*
Never
0
1
2
3
4
Always
5
0 is Never, 5 is Always
I have felt anxious.
*
Never
0
1
2
3
4
Always
5
0 is Never, 5 is Always
I have felt depressed.
*
Never
0
1
2
3
4
Always
5
0 is Never, 5 is Always
I have felt irritable.
*
Never
0
1
2
3
4
Always
5
0 is Never, 5 is Always
I have felt that my sleep problem could affect my personal relationships.
*
Never
0
1
2
3
4
Always
5
0 is Never, 5 is Always
I have felt embarrassed about my sleep problem.
*
Never
0
1
2
3
4
Always
5
0 is Never, 5 is Always
My sleep problem affects my ability to function normally.
*
Never
0
1
2
3
4
Always
5
0 is Never, 5 is Always
I have been worried about the quality of my sleep.
*
Never
0
1
2
3
4
Always
5
0 is Never, 5 is Always
My sleep problem has made me worry about my health.
*
Never
0
1
2
3
4
Always
5
0 is Never, 5 is Always
Total Score
Tiredness Score
Alertness Score
Mood Score
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Next
Snoring Loudness Scale
Rate how loud is your snoring?
*
0 - Silent
1
2 - My snoring is easily heard but does not disturb
3
4 - My snoring disturbs my partner's sleep
5
6 - My snoring can be heard through a closed door
7
8 - My partner and I sleep in separate rooms because of my snoring
9
10 - My snoring is heard outside my home. Neighbours have complained.
NOSE Score
Over the past one month, how much of a problem were the following conditions for you?
Nasal congestion or stuffiness
*
Not a Problem
0
1
2
3
Severe Problem
4
0 is Not a Problem, 4 is Severe Problem
Nasal blockage or obstruction
*
Not a Problem
0
1
2
3
Severe problem
4
0 is Not a Problem, 4 is Severe problem
Trouble breathing through my nose
*
Not a Problem
0
1
2
3
Severe problem
4
0 is Not a Problem, 4 is Severe problem
Trouble sleeping
*
Not a Problem
0
1
2
3
Severe problem
4
0 is Not a Problem, 4 is Severe problem
Unable to get enough air through my nose during exercise or exertion
*
Not a Problem
0
1
2
3
Severe problem
4
0 is Not a Problem, 4 is Severe problem
Total Score
Back
Next
STOPBANG Questionnaire
Do you snore loudly enough to be heard through a closed door?
*
Yes
No
Do you often feel tired, fatigues or sleepy?
*
Yes
No
Has anyone observed you stop breathing or choking/gasping during your sleep?
*
Yes
No
Do you have, or are being treated for high blood pressure?
*
Yes
No
Is you Body Mass Index (BMI) more than 35 kg/m2?
*
Yes
No
BMI Calculator
Please use the calculator below to work out what your Body Mass Index (BMI) is. Be aware that the height needs to be in meters (e.g. 1.7 rather than 170cm). If your result is greater than 35, please answer the questions above as 'Yes'. If you already know your BMI, there is no need to use this calculator.
Height in meters
e.g. 1.7
Weight in Kg
e.g. 70
Your BMI =
Are you older than 50?
*
Yes
No
Is your shirt collar size 16 inches / 40cm or larger? (measured around Adams apple)
*
Yes
No
Are you male?
*
Yes
No
Result
Epworth Sleepiness Scale
This is a questionnaire that describes your chances of dozing off during the day whilst engaging in daily activities. How likely are you to dose off or fall asleep in the following situations, in contrast to feeling just tired? This refers to your usual way of life in recent times. Even if you have not done some of these things recently try to work out how they would have affected you.
What is the chance of you dozing in the following situations.
When answering, consider how you have felt in the last month:
Sitting and reading
*
Would never doze
Slight chance of dozing
Moderate chance of dozing
High chance of dozing
Watching TV
*
Would never doze
Slight chance of dozing
Moderate chance of dozing
High chance of dozing
Sitting, inactive in a public place (e.g. a theatre or a meeting)
*
Would never doze
Slight chance of dozing
Moderate chance of dozing
High chance of dozing
As a passenger in a car for an hour without a break
*
Would never doze
Slight chance of dozing
Moderate chance of dozing
High chance of dozing
Lying down to rest in the afternoon when circumstances permit
*
Would never doze
Slight chance of dozing
Moderate chance of dozing
High chance of dozing
Sitting and talking to someone:
*
Would never doze
Slight chance of dozing
Moderate chance of dozing
High chance of dozing
Sitting quietly after lunch without alcohol
*
Would never doze
Slight chance of dozing
Moderate chance of dozing
High chance of dozing
In a car, while stopped for a few minutes in traffic
*
Would never doze
Slight chance of dozing
Moderate chance of dozing
High chance of dozing
Total Score
Back
Next
Insomnia Severity Index
This questionnaire is widely used as a good initial assessment of insomnia as it helps clinicians determine an appropriate level of intervention for their sleep problem.
Rate the current (over the last 2 weeks) SEVERITY of your insomnia problem with Difficulty Falling Asleep
*
No problem
Mild problem
Moderate problem
Severe problem
Very Severe Problem
Rate the current (over the last 2 weeks) SEVERITY of your insomnia problem with Difficulty Staying Asleep
*
No problem
Mild problem
Moderate problem
Severe problem
Very Severe problem
Rate the current (over the last 2 weeks) SEVERITY of your insomnia problem with Problem Waking up too Early
*
No problem
Mild problem
Moderate problem
Severe problem
Very Severe problem
How SATISFIED are you with your current sleep pattern?
*
Very satisfied
Satisfied
In between
Dissatisfied
Very Dissatisfied
To what extent do you consider your sleep problems to INTERFERE with your daily functioning? (e.g. daytime fatigue, ability to function at work / daily chores, concentration, memory, mood etc.)
*
Not at all Interfering
A little interfering
Somewhat interfering
Much interference
Very much interfering
How NOTICEABLE to others do you think your sleeping problem is in terms of impairing the quality of your life?
*
Not at all noticeable
A little noticeable
Somewhat noticeable
Much (noticeable)
Very much noticeable
How WORRIED / Distressed are you about your current sleep problem?
*
Not at all worried
A little worried
Somewhat worried
Much (worried)
Very much worried
Total Score
Hospital Anxiety & Depression Scale
Choose answers that best describe how you have been feeling over the last 2 weeks. You do not have to think too much about each answer as spontaneous answers are more important.
I feel tense or wound up:
*
Not at all
From time to time
A lot of times
Most of the time
I still enjoy the things I used to:
*
Definitely as much
Not quite so much
Only a little
Hardly at all
I get a sort of frightened feeling as if something awful is about to happen:
*
Not at all
A little, but it doesn't worry me
Yes, but not too badly
Very definitely and quite badly
I can laugh and see the funny side of things:
*
As much as I always could
Not quite as much now
Definitely not so much now
Hardly at all
Worrying thoughts go through my mind:
*
Only occasionally
From time to time
A lot of times
Most of the time
I feel cheerful:
*
Most of the time
Usually
Not often
Not at all
I can sit at ease and feel relaxed:
*
Definitely
Usually
Not often
Not at all
I feel as if I am slowed down:
*
Not at all
From time to time
Very often
Nearly all the time
I get a sort of frightened feeling like butterflies in the stomach
*
Not at all
From time to time
Quite often
Very often
I have lost interest in my appearance:
*
I take as much care as ever
I may not take quite as much care
I don't take as much care as I should
Definitely
I feel restless, as if I have to be on the move:
*
Not at all
Not very much
Quite a lot
Very much indeed
I look forward with enjoyment of things:
*
As much as I ever did
A little less than I used to
Definitely less than I used to
Hardly at all
I get a sudden feeling of panic:
*
Not at all
From time to time
Quite often
Very often indeed
I can enjoy a good TV, radio program or book:
*
Often
Sometimes
Not often
Hardly at all
Depression Score
Anxiety Score
You have Completed the Questionnaires!
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