Stop Bang Questionnaire 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)? yes no Tiredness/fatigue: Do you often feel tired, fatigued, or sleepy during the daytime, even after a “good” night’s sleep? yes no Observed: Has anyone ever observed you to stop breathing during your sleep? yes no Pressure: Do you have or are you being treated for high blood pressure? yes no Body Mass Index: More then 35? (BMI Formula: weight (lb) / Height (in)2 x 703) yes no Age: Age older than 50? yes no Neck size: Does your neck measure more than 15 ¾ inches (40 cm) around? yes no Gender: Are you male? yes no 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 0 1 2 3 Watching television 0 1 2 3 Sitting inactively in a public place (For example, a theater or meeting) 0 1 2 3 As a passenger in a car for an hour without a break 0 1 2 3 Lying down to rest in the afternoon 0 1 2 3 Sitting and talking to someone 0 1 2 3 Sitting quietly after lunch (when you've had no alcohol) 0 1 2 3 In a care, while stopped in traffic 0 1 2 3 Total Score: Submit Form Your request has been sent -- we will be in contact with you shortly. There was an error! Please phone our office.