Survey

First Name *

Last Name *

Healthcard *

Day of birth*

Your Gender*

The questions listed are relevant to, and asked solely for, the purpose of effective medical diagnosis and treatment. Please provide any information that will make your visits us with us more comfortable.

How do you currently identify?

Your Biological Gender*

Name of your current family doctor or referring doctor: *

Do you currently have an appointment booked at the Sleep Disorders Clinic? *

Day Of Appointment *

I confirm that I will attend the appointment as scheduled

Your Address

Street Address *

City *

Country *

Province/State *

Postal/ZIP Code *

Home Phone*

Mobile Phone*

Other Phone*

Preferred Phone*

Email

Have you ever had a sleep study?*

When was the sleep study done (approximately)?

Where was the sleep study done?

Have you ever had a CPAP/BIPAP study?*

When was the CPAP/BIPAP study done (approximately)?

Where was the CPAP/BIPAP study done?

Please confirm whether or not you’ve had a sleep study performed AFTER
3 December 2021:*

Disclaimer: OHIP allows only one CPAP or BIPAP titration study in Ontario in a two year period. If you do not disclose that you have had a titration study done within this time frame you may be responsible for the full cost of the titration study if it is not reimbursed by OHIP.

Are you currently using a CPAP machine?*

What is the CPAP pressure you use?

Are you currently using a BIPAP machine?*

What is the BIPAP pressure you use?

If you are currently using CPAP or have used CPAP in the past where did you get your CPAP unit?*

Location city of CPAP vendor:

If you are currently using CPAP please answer the following questions:

Do you need a new CPAP machine? *

When did you get your last unit?

What kind of mask are you using? *

Describe mask

Do you currently have issues with CPAP?*

Please check off any of the following: Mask leak or other mask issues Snoring on CPAP Frequent awakenings Air swallowing Other problems:

Describe mask issues:

Describe other issues:

Do you have any of the following: Open wounds Current infections History of hospital acquired infections

Please provide additional details:

How likely are you to doze 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.
Use the following scale to choose the "most appropriate number" for each situation

Please answer these according to how you feel on CPAP:

0 = would "never doze"
1 = "slight" chance of dozing

2 = "moderate" chance of dozing
3 = "high" chance of dozing

Sitting and reading *

Watching T.V. *

Sitting, inactive in a public place *

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 stopped for a few minutes in traffic *

TOTAL:

Are you overweight?*

Preferred Unit of Measurement

What is your current weight in kilograms?*

What is your height in centimeters?*

What is your current weight in pounds?*

What is your height in feet and inches?*

Is your weight stable?*

Have you gained weight?*

Have you lost weight?*

Weight change?

Weight has changed over how long?

Is there anything else you would like the doctor to know for the follow up appointment (include medication, sleep, and PAP issues):

* Attention *

Your Address