Welcome to the Jacobs sleep consultation pre-survey

Please complete the Sleep survey below. Your results will be emailed to you.

Bodycare | Healthworks

PERSONAL DETAILS

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Date of Birth (required field)
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What's your gender?
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RELEASE OF INFORMATION AND PARTICIPATION CONSENT
Participant Release of Information Consent pursuant to Federal Privacy Act 1988 (AU) or Privacy Act 1993 (NZ)



  • I confirm that my participation in this sleep consultation is voluntary.


  • I acknowledge that any personally identifiable health information obtained in conjunction with this sleep consultation will be protected and will only be used in accordance with this agreement and applicable laws pertaining to the use of personal health information.


  • I understand that any health information obtained, may be used to compile a deidentified aggregate report for my company/employer. While my employer may be notified of my participation, my individually identifiable health information will not be shared with my employer.


  • I understand that the scores on the following self-assessment do not reflect any particular diagnosis or course of treatment. The data collected does not constitute a diagnosis. The responsibility for initiating a follow-up assessment to confirm the results of this survey and obtain professional assistance is mine alone and not that of my employer or any organisation associated with this survey.


    • I hereby give Bodycare Health & Wellbeing Pty Ltd consent to release the de-identified results of my sleep consultation as part of an aggregate result to the relevant department of my employer.
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    Consent
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    EPWORTH SLEEPINESS SCALE

    The Epworth Sleepiness Scale is a questionnaire to measure daytime sleepiness. 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:.



    The rating scale is as follows:

    0 - no chance of dozing

    1 - slight chance of dozing

    2 - moderate chance of dozing

    3 - high chance of dozing

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    The situations are below:

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    1. Sitting and reading
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    2. Watching TV
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    3. Sitting inactive in a public place (e.g. a theatre or a meeting)
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    4. As a passenger in a car for an hour without a break
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    5. Lying down to rest in the afternoon when circumstances permit
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    6. Sitting and talking to someone
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    7. Sitting quietly after a lunch without alcohol
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    8. In a car, while stopped for a few minutes in traffic
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    Understanding Your Score

    Your Score
    0
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    Understanding your score

    • 0–10: Normal range in healthy adults

    • 11–14: Mild sleepiness

    • 15–17: Moderate sleepiness

    • 18+: Severe sleepiness

    If you scored 10 or more, discuss this with your GP to diagnose and treat the cause of your sleepiness.

    Reference: Johns MW. A new method for measuring daytime sleepiness: the Epworth sleepiness scale. Sleep 1991: 14(6):540-5.

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    SLEEP DISORDER SURVEY

    If you spend a great deal of time lying awake in bed at night or frequently nod off during the day, you may have a sleep disorder. A variety of sleep disorders can cause similar symptoms, such as excessive daytime sleepiness. Insomnia and sleep apnoea are the two most common sleep disorders.

    The short survey below can indicate if you may have a sleep disorder.

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    I feel sleepy during the day, even when I get a good night's sleep.
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    I get very irritable when I can't sleep.
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    I often wake up at night and have trouble falling back to sleep
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    It usually takes me a long time to fall asleep.
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    I often wake up very early and can’t fall back to sleep.
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    I experience an uncomfortable/restless sensation in my legs at night.
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    My legs often move or jerk during the night.
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    I sometimes wake up gasping for breath.
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    My bed partner says my snoring keeps her/him from sleeping.
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    I have fallen asleep while driving.
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    If you answered yes to any of the above statements you may have a sleep disorder. You should discuss your results with your GP.

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    When you hit the submit button, the form may take a little while to process. Please do not hit the back button or close the browser while the form is submitting.

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    Submit

    Once you have completed your survey, you’ll receive your responses via email. Please bring these along to your consultation.