Epworth/STOP BANG Sleep Questionnaire

Sleep Apnea Patient Questionnaire
Patient Name*

First NameMiddle NameLast Name
Date*

MonthDayYear
Date
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.

	Yes	No
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 APNEA - 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 - Are you older than 50 years?
NECK SIZE - Does your neck measure more than 15 ¾ inches (40 cm) around?
GENDER - Are you male?

	0	1	2	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 car, when stopped in traffic

Sleep Apnea Patient Questionnaire