Sleep Well Clinic Referral Form and Snoring, Sleepiness, and Epworth Sleepiness Score (click for printable PDF):
The Sleep Well Clinic referral form is not essential for making an appointment. However, it does provide a good summary of relevant information to help us triage patients before making appointments.
The information helps us identify which patients might need testing prior to consultation, and which patients might be better served to go straight to consultation with one of the Sleep Well Clinic doctors or clinical service providers.
The first page has contact information for the patient and also for the General Practitioner. There is space for recording the scores form the three questionnaires on the reverse side of the referral form, so that only the front page need be faxed to the clinic.
The second page has three questionnaires. The first two are a 5-point snoring status questionnaire, and a 5-point sleepiness status questionnaire. They both rank snoring and daytime sleepiness according to self-reported frequency: never, rarely, sometimes, often, always (Zieliński et al., 1999). We have found these two questionnaires to be very useful adjuncts to the Epworth Sleepiness Questionnaire, which itself is a simple, 8-item self-administered questionnaire in wide use, and shown to provide a measurement of the subject’s general level of daytime sleepiness.
The snoring questionnaire tells us there is increased airway resistance during sleep which is a potential mechanism for sleep disturbance. The two sleepiness questionnaires give us a sense of the impact of sleep disturbance on daytime functioning. One asks about feeling sleepy, and the other asks about actually falling asleep. In other words, once is asking about the battle, and the other is asking about losing the fight.