Stop Bang Questionnaire Patient Name: Date: Is it possible that you have Obstructive Sleep Apnea (OSA) Please answer the following questions to determine if you might be at risk. Snoring? Do you snore Loudly (loud enough to be heard through closed doors or your bed-partner elbows you for snoring at night)? yes no Tired? Do you often feel Tired, Fatigued, or Sleepy during the daytime (such as falling asleep during driving or talking to someone)? yes no Observed? Has anyone observed you Stop Breathing or Choking/Gasping during your sleep? yes no Pressure? Do you have or are being treated for High Blood Pressure? yes no Body Mass Index Calculator? •cm / kg •inches/lb Height: Weight: Calculate BMI: Body Mass Index more than 35 kg/m²? yes no Age older than 50? yes no Date: Submit Form Your request has been sent -- we will be in contact with you shortly. There was an error! Please phone our office.