TRS - Waterloo Sleep Institute Post-Sleep Questionnaire
For Waterloo Sleep Institue patients, please fill out after your sleep study is complete.
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
How would you rate your sleep study?
Excellent
Good
Fair
Poor
How long do you estimate it took you to fall asleep last night?
Please Select
00 to 15 Minutes
15 to 30 Minutes
30 to 45 Minutes
45 to 60 Minutes
1 to 2 Hours
2 to 3 Hours
3 to 4 hours
4+ Hours
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 urinate
Equipment uncomfortable
Equipment Noise
Anxiety
Tension
Fear of Test
Dreams/Nightmares
If dreams/nightmares or other, please explain:
Estimate your sleep time
Please Select
00 to 15 Minutes
15 to 30 Minutes
30 to 45 Minutes
45 to 60 Minutes
1 to 2 Hours
2 to 3 Hours
3 to 4 hours
4 to 5 Hours
5 to 6 Hours
6 to 7 Hours
7 to 8 Hours
How did you feel upon wakening?
Alert/Awake/Energetic
Functioning at high level/Able to concentrate
Foggy/Drowsy
Not Alert
Sleepy/Woozy/Want to return to bed
Cannot stay awake
Overall, was last night’s sleep similar to your normal sleep at home?
Yes
No
If No please explain
Do you feel that you were provided with enough information at the time of booking your sleep study?
Yes
No
Did the technical staff explain testing procedures clearly?
Yes
No
Were the technical staff attentive to your general needs while at the sleep laboratory?
Yes
No
How would you rate your overall experience in the sleep laboratory?
Excellent
Good
Fair
Poor
Do you have any additional comments/ suggestions you would like to share with us?
Submit
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