SLEEP ASSESSMENT
Dr Sudeshan Govender
Sleep Health Screening by Khaya HealthTechWelcome,This questionnaire will provide you with insights to your sleep health. The questionnaire is specifically for people who usually work during the day (i.e. do not work night- or rotating-shifts). We will ask you for demographic information, your sleep habits, your health status, and how your sleep affects your daily life.
Sleep Health Screening by Khaya HealthTechYou and Dr Sudeshan Govender 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.
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
Email
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?
Please select any of medical conditions you have been diagnosed with (select all that apply):
High blood pressure
Diabetes
Insomnia
Sleep Apnoea
Narcolepsy
Cardiovascular Disease
None of the above
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:
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?
For this section, please answer according to your typical weekend activity, when you do not have any morning or evening commitments.
On weekends:
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
How 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?
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, theater, 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?
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?
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
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
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
You have completed the Sleep Questionnaire. Review or change your answers by navigating to previous pages, or submit your response below.
After submission, your personalised results will be emailed to you within a few minutes.
Submit
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