STOP-BANG Patient Questionnaire

Please answer the questions below to help us see if you might have sleep apnea. This is when your breathing pauses sometimes while you are sleeping.


Snoring:
Do you snore loudly (louder than talking or loud enough to be heard through closed doors)?

Tiredness/fatigue:
Do you often feel tired, fatigued, or sleepy during the daytime, even after a “good” night’s sleep?

Observed:
Has anyone ever observed you to stop breathing during your sleep?

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

Body Mass Index:

More then 35? (BMI Formula: weight (lb) / Height (in)2 x 703)


Age:
Age older than 50?

Neck size:
Does your neck measure more than 15 ¾ inches (40 cm) around?

Gender:
Are you male?

 
Epworth Sleepiness Scale

The Epworth Sleepiness Scale is widely used in the field of medicine as a subjective measure of a patient’s sleepiness. How likely are you to doze off or fall asleep during he following situations, in contrast to just feeling tired?

For each of the situations listed below, give yourself a score of 0 to 3
0= Would never doze; 1= Slight chance; 2= Moderate chance; 3=High chance

 
Situation
Chance of dozing (0-3)
Sitting and reading
Watching television
Sitting inactively in a public place (For example, a theater or meeting)
As a passenger in a car for an hour without a break
Lying down to rest in the afternoon
Sitting and talking to someone
Sitting quietly after lunch (when you've had no alcohol)
In a care, while stopped in traffic

Total Score:
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