Pre-consultation: Sleep Optimisation

First name *

Last name *

Email *

Phone *

Date of birth *

How likely are you to doze off or fall asleep in the following situations? 1. Sitting and reading *

ESS total 0-24. Score 10+ suggests excessive daytime sleepiness. Rate your likelihood of dozing in each situation.

2. Watching TV *

3. Sitting inactive in a public place (e.g. theatre, meeting) *

4. As a passenger in a car for an hour without a break *

5. Lying down to rest in the afternoon *

6. Sitting and talking to someone *

7. Sitting quietly after lunch without alcohol *

8. In a car, while stopped for a few minutes in traffic *

Do you Snore loudly (as reported by others)? *

STOP-BANG score 0-2 = low risk, 3-4 = intermediate risk, 5-8 = high risk for obstructive sleep apnoea.

Yes

No

Do you often feel Tired, fatigued, or sleepy during the daytime? *

Yes

No

Has anyone Observed you stop breathing during sleep? *

Yes

No

Do you have or are you being treated for high blood Pressure? *

Yes

No

BMI > 35 kg/m²? (If unsure, we can calculate from your height and weight) *

Yes

No

Unsure - will calculate from height/weight

Age > 50 years? *

Yes

No

Neck circumference > 40 cm (16 inches)? *

Yes

No

Unsure

Male gender? *

Yes

No

What time do you typically go to bed? *

Use 24-hour format (e.g. 22:30)

What time do you typically try to fall asleep?

If different from bedtime (e.g. if you read or scroll first)

How long does it take you to fall asleep after trying? *

Less than 15 minutes

15-30 minutes

30-60 minutes

More than 1 hour

More than 2 hours

How many times do you typically wake during the night? *

0 (sleep straight through)

1-2 times

3-4 times

5 or more times

What wakes you during the night? (select all that apply)

Need to urinate

Pain

Noise

Partner

Anxiety or racing thoughts

Nightmares

Sleep apnoea or feeling like I'm choking

Hot flushes

Don't know / no specific reason

How long does it take you to fall back asleep after waking?

Less than 15 minutes

15-30 minutes

30-60 minutes

More than 1 hour

Very difficult to get back to sleep

What time do you typically wake in the morning? *

Your natural wake time or alarm time?

Do you wake before your alarm (if you use one)?

Waking 1-2 hours early consistently is a classic sign of depression - your doctor will explore this

No

Sometimes

Often - usually 1-2 hours earlier than intended

How many hours of sleep do you get per night (on average)? *

Less than 4 hours

4-5 hours

5-6 hours

6-7 hours

7-8 hours

8-9 hours

More than 9 hours

How would you rate your overall sleep quality? *

Very poor

Poor

Fair

Good

Excellent

How much screen time (phone, tablet, laptop) do you have in the hour before bed? *

None

30 minutes

1 hour

2 or more hours

How many caffeine-containing drinks do you have per day? (coffee, tea, energy drinks, cola) *

None

1

2

3

4+

When do you have your last caffeine drink?

Time of day (e.g. 14:00). Caffeine after 2pm can affect sleep

Do you drink alcohol before bed? *

Never

Occasionally (few times a month)

Regularly (few times a week)

Most nights

If you drink before bed, how many units per night? (UK standard: 1 unit = 10ml pure alcohol)

0-1 unit

1-2 units

2-4 units

4+ units

When do you exercise, relative to bedtime?

Morning

Afternoon

Evening (more than 2 hours before bed)

Evening (within 2 hours of bed)

I don't exercise regularly

Are there environmental issues affecting your sleep? (select all that apply)

Too hot

Too cold

Too bright

Too noisy

Uncomfortable bed/pillows

Partner disturbs sleep

None - environment is fine

Do you work shift work or have irregular hours?

Yes

No

Do you frequently travel across time zones (jet lag)?

Yes, regularly

Occasionally

No

What have you already tried to improve your sleep? (select all that apply)

Sleep apps or meditations

Melatonin

Over-the-counter sleep aids (e.g. Nytol)

Prescription sleeping pills

CBT-i (Cognitive Behavioural Therapy for Insomnia)

Sleep restriction therapy

Relaxation techniques or breathing exercises

Nothing yet

Are you currently taking or have you taken prescription sleeping pills?

Currently taking

Taken in the past

Never taken

Do you experience racing thoughts or an active mind at bedtime?

Yes, very often

Occasionally

No

Do you feel anxious about not being able to sleep? (This can create a vicious cycle)

Yes, very anxious

Somewhat anxious

Not really

Do you have chronic pain that affects your sleep?

Yes

No

Do you experience restless legs or involuntary leg movements during sleep?

Yes

No

Not sure - partner has mentioned it

Do you experience acid reflux or heartburn at night that wakes you?

Yes, frequently

Occasionally

No

Are you being treated for reflux?

Yes

No

Do you have depression or anxiety?

Yes, diagnosed and treated

Yes, suspected but not diagnosed

No

Do you have asthma, COPD, or other breathing conditions that affect sleep?

Yes

No

Have you been diagnosed with or suspect you may have sleep parasomnias? (sleepwalking, sleep talking, acting out dreams, teeth grinding)

Yes

No

Not sure

Are you perimenopausal or menopausal? Do night sweats affect your sleep?

Yes, night sweats disrupt my sleep

Yes, but managed

No

Do you wake frequently at night to urinate (more than twice)?

Yes

No

Do you use a sleep tracker or smartwatch that monitors sleep?

Yes

No

What is your average sleep score from your tracker?

What is your average deep sleep? (hours or percentage)

What is your average REM sleep? (hours or percentage)

Do you know your resting heart rate?

Do you know your HRV (Heart Rate Variability)?

List all medications you're currently taking (including over-the-counter)

Some medications (antidepressants, beta-blockers, corticosteroids, stimulants, decongestants) can significantly affect sleep

What are you hoping to achieve from this consultation? (select all that apply) *

Understand why I can't sleep

Improve my sleep quality

Screen for sleep apnoea

Get a prescription for sleeping medication

Come off sleeping pills safely

General sleep advice and optimization

Optimize sleep for athletic/physical recovery

Is there anything else about your sleep we should know?

Here's what you've told us. Have a quick check, then hit send - this means your consultation can focus on what actually matters to you.

Your details

Name

Email

Phone

Date of birth

Epworth Sleepiness Scale (ESS)

How likely are you to doze off or fall asleep in the following situations? 1. Sitting and reading -

2. Watching TV -

3. Sitting inactive in a public place (e.g. theatre, meeting) -

4. As a passenger in a car for an hour without a break -

5. Lying down to rest in the afternoon -

6. Sitting and talking to someone -

7. Sitting quietly after lunch without alcohol -

8. In a car, while stopped for a few minutes in traffic -

STOP-BANG Sleep Apnoea Screen

Do you Snore loudly (as reported by others)? -

Do you often feel Tired, fatigued, or sleepy during the daytime? -

Has anyone Observed you stop breathing during sleep? -

Do you have or are you being treated for high blood Pressure? -

BMI > 35 kg/m²? (If unsure, we can calculate from your height and weight) -

Age > 50 years? -

Neck circumference > 40 cm (16 inches)? -

Male gender? -

Your Sleep Pattern

What time do you typically go to bed? -

What time do you typically try to fall asleep? -

How long does it take you to fall asleep after trying? -

How many times do you typically wake during the night? -

What wakes you during the night? (select all that apply) -

How long does it take you to fall back asleep after waking? -

What time do you typically wake in the morning? -

Do you wake before your alarm (if you use one)? -

How many hours of sleep do you get per night (on average)? -

How would you rate your overall sleep quality? -

Sleep Hygiene

How much screen time (phone, tablet, laptop) do you have in the hour before bed? -

How many caffeine-containing drinks do you have per day? (coffee, tea, energy drinks, cola) -

When do you have your last caffeine drink? -

Do you drink alcohol before bed? -

If you drink before bed, how many units per night? (UK standard: 1 unit = 10ml pure alcohol) -

When do you exercise, relative to bedtime? -

Are there environmental issues affecting your sleep? (select all that apply) -

Do you work shift work or have irregular hours? -

Do you frequently travel across time zones (jet lag)? -

Sleep Difficulties Detail

What have you already tried to improve your sleep? (select all that apply) -

Are you currently taking or have you taken prescription sleeping pills? -

Do you experience racing thoughts or an active mind at bedtime? -

Do you feel anxious about not being able to sleep? (This can create a vicious cycle) -

Medical Conditions Affecting Sleep

Do you have chronic pain that affects your sleep? -

Do you experience restless legs or involuntary leg movements during sleep? -

Do you experience acid reflux or heartburn at night that wakes you? -

Are you being treated for reflux? -

Do you have depression or anxiety? -

Do you have asthma, COPD, or other breathing conditions that affect sleep? -

Have you been diagnosed with or suspect you may have sleep parasomnias? (sleepwalking, sleep talking, acting out dreams, teeth grinding) -

Are you perimenopausal or menopausal? Do night sweats affect your sleep? -

Do you wake frequently at night to urinate (more than twice)? -

Wearable & Tracker Data

Do you use a sleep tracker or smartwatch that monitors sleep? -

What is your average sleep score from your tracker? -

What is your average deep sleep? (hours or percentage) -

What is your average REM sleep? (hours or percentage) -

Do you know your resting heart rate? -

Do you know your HRV (Heart Rate Variability)? -

Current Medications

List all medications you're currently taking (including over-the-counter) -

Your Sleep Goals

What are you hoping to achieve from this consultation? (select all that apply) -

Is there anything else about your sleep we should know? -

Upload supporting documents

Previous sleep study results if available.

Click to upload files

Anything else for your doctor?