Has anyone ever observed you stop Observed apnoea: breathing during your sleep? Are you being treated for high blood Pressure: pressure? Height (meters): _______ Body mass index over 35: Weight (kg): _______ BMI: _______ Are you older than 50 years? Age: Does your neck measure more than 40 Neck size: cm around? If yes, what is the measurement? _______ cm Are you male? Gender: Score If you have answered Yes to 3 or more of these questions, there is a likelihood of Obstructive Sleep Apnoea. Consultants: Dr P J H Venn MB FRCA Dr A Nisbet FRCP BM BS Dr J C Ratoff MBBS MRCP www.1stopsnoring.co.uk Dear Patient, All NHS Trusts are required by the Government to collect the ethnic category of each of their patients. This will help to identify the varying needs of the different communities and highlight any areas where there is a shortfall in service provision. On a more practical level, it can be used to implement multi-language signs and help provide food suitable for the needs of different ethnic groups. This information is STRICTLY CONFIDENTIAL and will only be used by authorised staff. Please circle the letter which relates to your ethnic group. Please return this letter with your questionnaire or hand it back to a member of staff. Thank you for your time.
Observed apnoea: Has anyone ever observed you stop breathing during your sleep? Pressure: Are you being treated for high blood pressure? Body mass index over 35: Height (meters): _______ Weight (kg): _______ BMI: _______ Age: Are you older than 50 years? Neck size: Does your neck measure more than 40 cm around? If yes, what is the measurement? _______ cm Gender: Are you male? Score If you have answered Yes to 3 or more of these questions, there is a likelihood of Obstructive Sleep Apnoea. Consultants: Dr P J H Venn MB FRCA Dr A Nisbet FRCP BM BS Dr J C Ratoff MBBS MRCP www.1stopsnoring.co.uk Dear Patient, All NHS Trusts are required by the Government to collect the ethnic category of each of their patients. This will help to identify the varying needs of the different communities and highlight any areas where there is a shortfall in service provision. On a more practical level, it can be used to implement multi-language signs and help provide food suitable for the needs of different ethnic groups. This information is STRICTLY CONFIDENTIAL and will only be used by authorised staff. Please circle the letter which relates to your ethnic group. Please return this letter with your questionnaire or hand it back to a member of staff. Thank you for your time.
General-Medical-Questionnaire-New-Electronic-2017-2-doc.docx