Khaya Healthtech

SLEEP ASSESSMENT

Dr Jane Doe

Sleep Health Screening by Khaya HealthTech

Welcome,

This questionnaire is designed to provide you with insights to your sleep health. In consists of questions found in a variety of sleep assessment tools. This allows us to give you informative feedback on your sleep health.

Sleep Health Screening by Khaya HealthTech

You and Dr Doe will receive your results via email after completion of the survey.

This survey is conducted in accordance with the Protection of Personal Information Act (POPIA). Your personal and health-related information will be handled with the utmost confidentiality and used solely for the purposes of this research. Participation is voluntary. You may withdraw at any point without penalty. No identifiable personal information will be published or shared. Your responses will be anonymized or de-identified wherever possible. Data will be stored securely and only accessible to the authorised Khaya HealthTech representative.

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Disclaimer
The questionnaire you are about to complete is intended to screen for possible risk of sleep-apnoea or related sleep‐breathing issues. It is not a diagnostic test, and it does not substitute for a full medical examination, sleep study, or consultation with a qualified healthcare provider.

The results which you submit will generate a report for your nominated GP. This report is for informational purposes only, and any decision regarding diagnosis, monitoring, or treatment should be made by your healthcare provider.

If you are experiencing severe symptoms, such as stopping breathing during sleep, excessive daytime sleepiness, choking or gasping during sleep, loud snoring with witnessed pauses, or other serious health issues — you should seek urgent medical advice rather than relying solely on this screening tool.

By providing your consent, you acknowledge that you have read and understood the purpose of this survey and you voluntarily consent to the collection and processing of your personal and health information for the indicated purposes. You may contact us at any time for queries, corrections, or to request deletion of your data.

Name and Surname

Background Information

What year were you born?

How much do you weigh? (kg)

How tall are you? (cm)

What is your waist circumference? (in)

(Your pant size can be used to estimate this)

Is your neck circumference greater than 40cm?

What sex were you assigned at birth?

Sleep Duration & Quality

Sleep Duration & Quality

The next sections will ask you about your sleep habits on weekdays and weekends.

For this section, please answer regarding your typical weekday activity.

On weekdays:

The next sections will ask you about your sleep habits on weekdays and weekends.

For this section, please answer regarding your typical weekday activity.

On weekdays:

What time do you usually get into bed at night? 24hr format

What time do you usually fall asleep? 24hr format

What time do you usually wake up in the morning? 24hr format

What time do you usually get out of bed in the morning? 24hr format

Do you use an alarm clock?

Sleep Duration & Quality

For this section, please answer according to your typical weekend activity, when you do not have any morning or evening commitments.

On weekends:

For this section, please answer according to your typical weekend activity, when you do not have any morning or evening commitments.

On weekends:

What time do you usually get into bed at night? 24hr format

What time do you usually fall asleep? 24hr format

What time do you usually wake up in the morning? 24hr format

What time do you usually get out of bed in the morning? 24hr format

Do you use an alarm clock?

Sleep Duration & Quality

Sleep Duration & Quality

On a scale of 1 to 5, how difficult do you find it to fall asleep?

On average, how many times per night do you wake up?

How do you feel when waking up in the morning?

Daytime Sleepiness & Fatigue

Daytime Sleepiness & Fatigue

How often do you feel tired, fatigued, or sleepy during the day?

How often do you struggle to concentrate due to fatigue?

How often do you have headaches in the morning?

How likely are you to fall asleep while sitting and reading?

Daytime Sleepiness & Fatigue

Daytime Sleepiness & Fatigue

How likely are you to fall asleep while watching TV?

How likely are you to fall asleep while sitting inactive in a public space? For example, in a meeting, theatre, or dinner.

How likely are you to fall asleep as a passenger in a car for an hour or more without taking a break?

How likely are you to fall asleep while lying down to rest when circumstances permit?

Daytime Sleepiness & Fatigue

Daytime Sleepiness & Fatigue

How likely are you to fall asleep while sitting and talking to someone?

How likely are you to fall asleep while sitting quietly after a meal without alcohol?

How likely are you to fall asleep in a car while stopped for a few minutes in traffic or at a light?

Snoring & Breathing Irregularities

Do you snore loudly (louder than talking or heard through a closed door)?

Has anyone told you that you stop breathing while sleeping?

Do you wake up gasping for air or choking?

Do you frequently wake up with a dry mouth or sore throat?

Risk Factors for Sleep Disorders

How many cigarettes do you smoke in a day?

In the last month, on how many days did you drink alcohol?

On the days that you had alcohol, how many drinks did you have?

Risk Factors for Sleep Disorders

Do you use alcohol to help you fall asleep?

Do you use any non-prescription medication to help you fall asleep? (melatonin, CBD, Rescue, magnesium, etc)

Do you use any prescription medication to help you fall asleep?

Impacts of Sleep on Daily Life

Impacts of Sleep on Daily Life

Do you frequently experience mood swings or irritability?

Do you have difficulty remembering things?

Do you have difficulty making decisions?

Have you noticed changes in your sex drive or libido?

Your Sleep Chronotype

Your Sleep Chronotype

When would you prefer to do mentally demanding tasks (e.g., exams, studying)?

When would you perform best in 1 hour of physical exercise?

If you had to stay up late (e.g., until 04:00), how easy would that be for you?

How would you describe yourself?

Summary

Summary

You have completed the Sleep Questionnaire. Review or change your answers by navigating to previous pages, or submit your response below.

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