BreatheSleepWell Assessment

Welcome to the BreatheSleepWell Survey, from Bondi Respiratory and Sleep.

This is the first step in your journey to improving your health, so that you can breathe easier and sleep better.  This is a comprehensive assessment of all aspects that influence your respiratory and sleep health.  You may not think some of the questions apply to you, however, understanding the interaction between your other medical issues, medications, diet, weight, exercise and environment will be paramount in finding a tailored management plan to get you on the path to wellness. 

This online assessment will take approximately 20-45 minutes to complete, depending on the complexity of your medical background.

So let’s get started with some basic information!

Given Name/s *

Surname *

Email Address

Date of Birth *

Your Family

What is your marital status?

SingleDe factoMarriedSeparatedDivorcedWidowed

If you have a partner, what is their name?

Do you have Children?

YesNo

Please list their names and ages

Do they have any serious medical problems?

Do you have Grandchildren?

YesNo

What is the age range of your grandchildren?

Do you provide any care for your grandchildren? How many days/week?

Do your parents suffer any serious medical problems? If they are no longer alive, what did they die of?

Do you have Siblings?

YesNo

Do any of them have any serious medical problems?

Do any relatives have respiratory, allergy or sleep problems that you’re aware of?

Do you have any Pets?

YesNo

Please list what pets and how long you have had them

Have you ever had, lived with someone, or been exposed to tuberculosis?

YesNo

Please provide details

Who currently lives in your home?

Does anyone help you with your medical or home care? *

YesNo

Who helps you, how often and in what capacity? *

Your Medical History

Please list all medical diagnoses that you are currently being treated for, and what year they were first diagnosed

Please list all previous medical problems you have been treated for in the past, and what year they were diagnosed. Include any surgical procedures here

Are you allergic to any medications?

YesNo

Please list:

Do you currently take any inhalers, puffers or nose sprays?

YesNo

Please list, including the name, dose, number of puffs, when they were commenced, and if you find them useful

Have you previously ever taken any other inhalers, puffers or nose sprays?

YesNo

Please list the name and when you took them, duration of use and whether they were useful or not

Please list all other Medications you take at the moment, including the Name, Dose and frequency

Do you take any supplements, herbs or minerals?

YesNo

Please list:

Do you receive any regular injections or infusions?

YesNo

Please list:

Which of the following vaccines have you received?

COVID-19 *

YesNo

Date and brand of most recent dose:

Influenza

YesNo

Date/year of most recent dose:

Pneumococcal

YesNo

Date/year of most recent dose

dTP (Tetanus & Whooping Cough)

YesNo

Date/year of most recent dose

Your Respiratory Health

Have you ever been told you have any of the following conditions:

AsthmaPneumoniaEmphysemaBronchitisBronchiectasisLung FibrosisPulmonary Embolism (Clots in the lung) Pulmonary Hypertension

Other

Please list:

Did you have any serious respiratory illnesses as a newborn, child or teen?

YesNo

Please describe in more detail

Have you ever seen a Respiratory Specialist before? *

YesNo

Who did you see and why, what was the management plan and outcomes?

Have you ever had lung function testing before? *

YesNo

When and where was this done?

---

General Respiratory Health

How frequently do you get colds or flu like symptoms?

How many times in the last 12 months have you needed antibiotics for a chest infection?

How many hospital admissions have you ever had for breathing problems?

Have you ever been in the intensive care unit because of breathing problems?

YesNo

---

Breathing

Do you have trouble with your breathing on a day to day basis? *

YesNo

How long have you noticed you’ve been short of breath? *

Do you get Short of Breath:

Only with strenuous ExerciseShort of breath when walking up a slight hill or hurrying on the flatWhen walking on the flat, at a gentle pace, and needs to stop after 15minutes or about 1kmWhen on the flat, and needs to stop every few minutes or about 100mToo breathless to leave the house, or with dressing or showering

Do any of the follow apply to your shortness of breath (tick all that apply):

Worse with lying flatWorse when bending overWakes you in the middle of the nightIs associated with chest painIs associated with sweatingI get wheezyI hear crackles in my chestI have noisy breathingIts painful when I breath in deeplyI get numbing and tingling around my lips when I’m breathlessI become faint or dizzy when I get breathlessWorse on humid or hot days

Do you use Ventolin?

YesNo

If you use Ventolin to relieve your breathlessness, how many puffs of Ventolin would you use a day?

How many canisters of Ventolin would you use a year?

Do you have a “Preventer inhaler"?

YesNo

Many people who are prescribed a preventer inhaler don’t remember to take it every day. 

How many days per week do you remember to use your preventer inhaler? None at allOnce a weekTwice a weekAbout half the weekMost of the weekAlmost alwaysEvery day without fail

Do you find it easier to remember to take your preventer medication in the morning or evening?MorningsEveningsSimilar between mornings and evenings

---

Cough

Do you cough? *

YesNo

How long has your cough been a problem?Less than a month 1-3 months3-12 months1-5 yearsMore than 5 years

Which of the following describes your typical cough (tick all that apply):

Dry soundingWet soundingBarkyProductive of clear phlegmProductive of coloured phlegmI cough up bloodI have bursts/fits of coughingI sometimes cough until I vomitI experience cough-associated incontinence

Other

Please describe

Is your cough constantly problematic, or does it come and go?

Its constant all year round and never goes awayIt gets worse in some seasons, and better in othersIt comes and goes without any apparent patternOther

When is your cough worse (tick all that apply):

At NightWhen lying downAfter mealsAfter certain foods, eg: chilli, dairyAfter alcoholAt Work (but better at home)At Home (but better away from home)With bushfire smoke-hazeWith passive cigarette smoke exposureWhen exposed to perfumes or strong scents

Other

What other patterns or triggers for your cough have you noticed?

What treatments have you tried for your cough? Were they helpful?

Does your cough significantly bother you?

YesNo

Please complete these four validated assessments of your cough:

1. CSI

Within the last Month, how did the following problems affect you?

0 = Never1 = Almost never2 = Sometimes3 = Almost always4 = Always

My cough is worse when I lie down

0 = Never1 = Almost never2 = Sometimes3 = Almost always4 = Always

My coughing causes me to restrict my person and social life

0 = Never1 = Almost never2 = Sometimes3 = Almost always4 = Always

I tend to avoid places because of my cough problem

0 = Never1 = Almost never2 = Sometimes3 = Almost always4 = Always

I feel embarrassed because of my coughing problem

0 = Never1 = Almost never2 = Sometimes3 = Almost always4 = Always

People ask, “What’s wrong?” Because I cough a lot.

0 = Never1 = Almost never2 = Sometimes3 = Almost always4 = Always

I run out of air when I cough.

0 = Never1 = Almost never2 = Sometimes3 = Almost always4 = Always

My coughing problem affects my voice.

0 = Never1 = Almost never2 = Sometimes3 = Almost always4 = Always

My coughing problem limits my physical activity

0 = Never1 = Almost never2 = Sometimes3 = Almost always4 = Always

My coughing problem upsets me

0 = Never1 = Almost never2 = Sometimes3 = Almost always4 = Always

People ask me if I am sick because I cough a lot.

0 = Never1 = Almost never2 = Sometimes3 = Almost always4 = Always

2. GCI (8)

Within the last Month, How did the following problems affect you?

0 = No Problem12345 = Severe Problem

Speaking takes extra effort

0 = No Problem12345 = Severe Problem

Throat discomfort or pain after using your voice

0 = No Problem12345 = Severe Problem

Vocal fatigue (voice weakens as you talk)

0 = No Problem12345 = Severe Problem

Voice cracks or sounds different

0 = No Problem12345 = Severe Problem

3. RSI (15)

Within the last Month, How did the following problems affect you?

0 = No Problem12345 = Severe Problem

Hoarseness or a problem with your voice

0 = No Problem12345 = Severe Problem

Clearing your throat

0 = No Problem12345 = Severe Problem

Excess throat mucous or postnasal drip

0 = No Problem12345 = Severe Problem

Difficulty swallowing food, liquids, pills

0 = No Problem12345 = Severe Problem

Coughing after you eat or after lying down

0 = No Problem12345 = Severe Problem

Breathing difficulty or choking episodes

0 = No Problem12345 = Severe Problem

Troublesome or annoying cough

0 = No Problem12345 = Severe Problem

Sensation of a lump in your throat

0 = No Problem12345 = Severe Problem

Heartburn, chest pain or indigestion

0 = No Problem12345 = Severe Problem

4. CCI

Within the last Month, how did the following problems affect you?

YesNo

Do you awaken from a sleep coughing violently, with or without trouble breathing?

YesNo

Do you have choking episodes when you cannot get enough air, or you gasp for air?

YesNo

Do you usually cough when you lie down in bed, or when you just lie down to rest?

YesNo

Do you usually cough after meals or eating?

YesNo

Do you cough when (or after) you bend over?

YesNo

Do you more or less cough all day long?

YesNo

Does change of temperature make you cough?

YesNo

Does laughing or chuckling cause you to cough?

YesNo

Do fumes (perfumes, car fumes, smoke, burned toast etc) cause you to cough

YesNo

Does speaking, singing, or talking on the phone cause you to cough?

YesNo

Your Allergies and Your Nose

Do you have food allergies?

YesNo

Please list:

Have you ever had Skin Prick testing or blood tests for allergies?

YesNo

What were the results?

Do you think you’re allergic to any of the following:

CatsDogsDust & DustmitePollensGrassesMould or mildew

Other:

Please List:

Have you ever been diagnosed with any of the following?

HayfeverAllergic RhinitisNasal polypsSinusitisEczemaBroken Nose

Other:

Please list:

Which of the following nasal symptoms do you experience?

Nasal itchFrequent sneezingRunny noseNose bleedsPost nasal dripBlocked noseReduced sense of smellSinus painRecurrent sinus infections

Other:

Please list:

Which of the following other symptoms do you experience?

Itchy skinItchy EyesWatery eyesRed eyesItchy throat or mouthFrequent sore throatsDry MouthHoarse voice

Other

Please list:

Are your symptoms worse at different times of the year or with known triggers?

YesNo

When are your symptoms worse?

Have you previously seen an Ear Nose and Throat Specialist? *

YesNo

Who did you see?

When did you last see them?

What were you seen for and what treatment(s) did you have?

Your Heart Health

Do you currently have any of the following symptoms?

High blood pressureLow blood pressureEpisodes of Chest painPalpitations (The feeling of your heart pounding in your chest)Irregular heart beatAbnormally fast heart ratePassing out or faintingDizziness when standing up too quicklyLeg or Calf pain when walkingAnkle swellingOther

If "Yes" or "Other" to any of the above, please explain in more detail:

Have you ever seen a Cardiologist? *

YesNo

Who did you see and when did you last see them?

What did you see them for?

Did they perform an echocardiogram (Ultrasound of the heart)?

YesNo

Did they perform an exercise test?

YesNo

Did they perform an angiogram?

YesNo

What were the results and management plan?

Do you have any upcoming plans to see a Cardiologist? *

YesNo

Your Stomach and Reflux

Do you experience any of the following symptoms:

Difficulty swallowingPainful swallowingFood regurgitationIntermittent nausea or vomitingOccassional acid or sour taste at the back of the mouthHeartburn or acid regurgitation, or a burning feeling behind your stomach or chestFrequent burping or belchingOtherNone

If "Yes" or "Other" to any of the above, please explain in more detail:

Do you use any over-the-counter antacids?

YesNo

How often do you take antacids for your reflux?

Have you ever seen a Gastroenterologist? *

YesNo

What did you see them for and when did you last see them?

What was the diagnosis and management plan?

Do you have any upcoming plans to see a Gastroenterologist? *

YesNo

Have you ever had a Gastroscopy (i.e. a camera inspection of your oesophagus and stomach)? *

YesNo

When, by who, and what was the result? *

Your Weight & Exercise

What is your height in centimeters (cm)?

How much do you currently weigh in kilograms?

How much did you weigh at your heaviest?

What was your lightest weight over the last 10 years?

What weight would you be happy with?

---

Have you unexpectedly lost weight over the last 6 months?

YesNo

How much weight have you lost unexpectedly?

Has your appetite changed over the last 6 months?

YesNo

Have you had any night sweats over the last 6 months?

YesNo

---

Have you tried any diets in the past to lose weight?

YesNo

What diets have been successful for you?

Have you ever seen a doctor to discuss weight loss?

YesNo

---

What physical activities do you currently do?

How often do you participate in physical activity?

Have you ever participated in a formal exercise program? *

YesNo

Please detail:

Your Home Environment

What best describes your current home:

HouseSemi-detachedTerraceTownhouseFlat/ApartmentCaravanFarmOther

Please describe:

What floor do you live on?

Is your home airconditioned?

YesNo

Is your home heated?

YesNo

Type of heater:GasFireplaceElectricOil heaterCentral or Ducted

Roughly, when was your building constructed:Less than 5 years ago5-10 years ago10-20 years ago20-40 years agoMore than 40 years ago

When was your home last renovated:Less than 5 years ago5-10 years ago10-20 years agoMore than 20 years ago

Are there any rising damp/mould issues in your home?

YesNo

Do you think your house has problems with excess dust?

YesNo

Is your house located within 50m of a major road?

YesNo

---

Is there carpet in your bedroom?

YesNo

How old is your bed mattress? Less than 1 year old1-2 years2-5 years5-10 yearsMore than 10 years

How old are your pillows? Less than 1 year old1-2 years2-5 years5-10 yearsMore than 10 years

Do you use any dustmite-proof mattress protectors or pillow cases?

YesNo

---

Who cleans your house and how regularly?

Does cleaning your house worsen your symptoms? *

YesNo

Your Sleep Patterns

Do you want to discuss any sleep problems? *

YesNo

How long has your sleep been a problem for you? *

How likely are you to doze off or fall asleep in the following situations (as opposed to just feeling tired) *

NeverSlight chanceModerate ChanceHigh Chance

Sitting and reading a book

NeverSlight chanceModerate ChanceHigh Chance

Watching television

NeverSlight chanceModerate ChanceHigh Chance

Sitting, inactive in a public place (eg: theatre, meeting)

NeverSlight chanceModerate ChanceHigh Chance

As a passenger in a car for more than an hour

NeverSlight chanceModerate ChanceHigh Chance

Lying down to rest in the afternoon

NeverSlight chanceModerate ChanceHigh Chance

Sitting and talking to someone

NeverSlight chanceModerate ChanceHigh Chance

Sitting quietly after lunch (without alcohol)

NeverSlight chanceModerate ChanceHigh Chance

As a driver in a car, while stopped in traffic

NeverSlight chanceModerate ChanceHigh Chance

Are you concerned about the quality of your sleep?

YesNo

Which of the following apply to you:

Don’t get enough sleepSleeping too muchOften nap during the dayWake unrefreshedRestless sleepLeg crampsFrequently need to urinate overnight

During the daytime, do you experience any of the following:

Morning headachesDry mouthNasal congestioonMicrosleeps while drivingPoor daytime concentration Memory problemsFatigueIrritability

How is your quality of sleep impacting your day-to-day personal and professional life?

Have you ever seen a sleep physician before?

YesNo

Who did you see and when?

Have you ever had a sleep study?

YesNo

When and where was the study, and what was the diagnosis?

Have you previously been diagnosed with a sleep problem?

YesNo

What were you diagnosed with and how was it treated?

Do you snore, or do you think you may snore?

YesNo

Which of the following statements are true for you:

My snoring seems to be getting worseMy partner has said I stop breathing in my sleepSnoring is worse on my backSnoring is worse after alcoholMy partner wears earplugs because of my snoringMy partner has had to sleep in another room because of my snoringI have had choking or gasping sensations during sleepI drool on the pillow

Have you experienced any of the following?

Sleep talkingSleep walkingSleep eatingActing out your dreamsA feeling when waking from sleep that you’re unable to move/paralysis Seeing things that aren’t real as you’re falling off to sleepSudden jerks as you’re falling off to sleepNight terrors (Screaming or yelling during bad dreams)Excessive kicking or leg movement during sleepHitting or punching things while asleepEpisodes during the day when laughing, crying or other emotional extremes where you then developed muscle weakness, buckled at the knee, collapsed or become paralysed

Do you have problems with insomnia (falling asleep, staying asleep or waking too early)?

YesNo

Please complete the following thinking about your sleep problems over the past 2 weeks:

0 - None1 - Mild2 - Moderate3 - Severe4 - Very Severe

I have had difficulty falling asleep

0 - None1 - Mild2 - Moderate3 - Severe4 - Very Severe

I have had difficulty staying asleep

0 - None1 - Mild2 - Moderate3 - Severe4 - Very Severe

I have had problems waking up too early

0 - None1 - Mild2 - Moderate3 - Severe4 - Very Severe

 

Very SatisfiedSatisfiedSomewhat SatisfiedDissatisfiedVery Dissatisfied

How satisfied are you with your current sleep pattern?

Very SatisfiedSatisfiedSomewhat SatisfiedDissatisfiedVery Dissatisfied

 

Not at allA littleSomewhatMuchVery much

How noticeable to others do you think your sleep problem is in terms of impairing your quality of life?

Not at allA littleSomewhatMuchVery much

How worried / distressed are you about your current sleep problem?

Not at allA littleSomewhatMuchVery much

To what extent do you consider your problem to interfere with your daily functioning?

Not at allA littleSomewhatMuchVery much

Do you use any medications to help you fall off to sleep?

YesNo

Which medications and how often?

Your Weekday Routine

What time do you go to bed?

What time do you go to sleep?

How long does it take you to fall asleep (after turning off the light and closing your eyes)?

How many times do you wake up overnight?

On average, how long are you awake for when you wake up?

What time do you wake up in the morning?

Do you wake up naturally or to an alarm clock?

How much sleep do you estimate you get overnight?

How much sleep do you think you need per night to feel rested?

During weekdays, do you have a daytime nap?

YesNo

What time do you take your nap?

How long do you nap for?

On weekends or holidays, do you sleep longer or have extra naps?

YesNo

Describe how your sleep differs:

What things have you tried to improve your sleep?

Your Bedroom Environment

Do you have a bed-partner?

YesNo

Is your room not dark enough overnight?

YesNo

Is your bedroom too noisy overnight?

YesNo

Is there a TV in your bedroom?

YesNo

Is it too hot or cold in your bedroom to sleep comfortably?

YesNo

Is there anything else that disturbs your sleep overnight?

Caffeine, Alcohol and Smoking

Caffeine:

Which of the follow Caffeinated beverages do you Drink?

Instant CoffeeEspresso CoffeeBlack TeaGreen TeaCola beveragesRed Bull / Mother / Energy DrinksI don’t drink caffeine

How many caffeinated drinks do you consume per day?

What time do you drink your last caffeinated drink in the day?

Alcohol:

On average, How many alcoholic drinks do you consume per day during the week?

How many alcoholic drinks might you consume on a big night?

How many days a week do you drink alcohol?

What is you preferred alcoholic beverage?

Tobacco Smoking:

Have you ever smoked a cigarette?

YesNo

What age did you start smoking?

At your worst, how many cigarettes did you smoke a day?

Are you still smoking?

YesNo

What age did you quit smoking?

How many cigarettes do you smoke a day now?

Have you previously quit smoking?

Would you like to quit smoking again?

Have you ever had significant passive smoke exposure?

YesNo

Where, how long ago, and for how long?

Vaping:

Have you ever tried vaping?

YesNo

Are you currently vaping?

What vaping liquid do you use?

How many times a day do you vape?

Would you like to quit vaping?

Other Drugs:

Do you currently, or have you previously, regularly inhaled other drugs? *

YesNo

If you would like to let the doctor know about other drug use, please indicate this here:

YesNo

Your Mental Health and Wellbeing

Have you ever been diagnosed or treated for any of the following?

DepressionBipolar disorderAnxietyEating disorderObsessive Compulsive DisorderAttention Deficit/Hyperactivity DisorderPersonality DisorderAutism Spectrum DisorderPost-Traumatic Stress DisorderSchizophrenia

Other

Please list:

Do you suffer with any types of chronic pain?

YesNo

Please describe:

Are you currently seeing a psychologist, therapist or psychiatrist for any reasons?

YesNo

If you feel comfortable, please describe in general terms what issues you are currently working through:

Over the past month, have you had any stress, mood or anxiety problems that has interfered with your day-to-day life?

YesNo

Your Occupation and Hobbies

What is your current occupation? If retired, how do you spend your time?

Please list your previous occupations:

Do you drive?

YesNo

Do you hold a commercial drivers licence?

YesNo

Have you had any car accidents in the last 5 years?

YesNo

Are you a shift-worker?

YesNo

What are your typical work hours?

Have you ever worked in any of the following roles:

Building Industry – including Roofing, electrical, carpentryNavy, including dockyard workers and sailorsFactory workBuilding maintenanceDemolitionKitchen installation or stone benchtop constructionSandstone excavationMinerFume or chemical workIndustrial cleanerEmergency workers / SES / Fire ServiceGrains / Flour

Do you enjoy any of the following hobbies:

Woodwork and CarpentryMetallurgyLeatherwork Home renovationGardening with soil exposureFeeding birds

What are your current hobbies and pursuits? *

Your International Travel

Were you born in Australia?

YesNo

Where were you born?

When did you migrate to Australia?

Have you ever lived overseas for more than 3 months?

YesNo

Where and for how long?

Have you ever travelled outside of Australia? *

YesNo

Where have you travelled? *

Western EuropeEastern EuropeMiddle East & North AfricaSub-Saharan AfricaIndian SubcontinentAsiaNew Zealand and Pacific IslandsSouth AmericaNorth America (USA & Canada)Central America (incl. Mexico)

We have covered a lot of information in the assessment.  Thank you for your cooperation and patience in completing this form.

If you have any previous notes, letters or reports you would like Dr Hamor to have a copy of, you can upload them here

Browse

If there is anything that was not covered that you would like to let the Doctor know, please let us know here:

Additional Information:

Please wait, files are uploading..

Submit

Save and Complete Later

×

Save and Complete Later

Your response has been saved, but not yet submitted.

To come back and continue later, please use this URL:

Copy URL

---

To receive the above link via email as well, enter your email address and click send.

Send

Back to form