* Attention *

This patient questionnaire is to be completed prior to all follow up appointments if the doctor has recommended treatment for a sleep disorder.

If this is your first visit to Sleep Disorders Clinic you should fill the full medical questionnaire at ONLINE PATIENT QUESTIONNAIRE: CLICK HERE

* Denotes Required Fields

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.

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

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.
Location city of CPAP vendor:

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

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 *

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