Adult Sleep Questionnaire
STOP | BANG SCREENING
Patient Name:
*
First Name
Last Name
Email
*
example@example.com
Mobile
Please enter a valid phone number.
Date Of Birth
*
-
Month
-
Day
Year
Do you SNORE loudly (louder than talking or loud enough to be heard through closed doors?)
*
Yes
No
Do you feel TIRED, fatigued, or sleepy during the day?
*
Yes
No
Has anyone OBSERVED you stop breathing during your sleep?
*
Yes
No
Do you have or are you being treated for high blood PRESSURE?
*
Yes
No
Your height
*
Your weight
*
AGE: Are you 50 years old or above?
*
Yes
No
Please list current medications.
*
NECK: Is your neck circumference greater than 16"?
*
Yes
No
GENDER: Are you male?
*
Yes
No
High risk of OSA: Yes 5-8 | Intermediate risk of OSA: Yes 3-4 Low risk of OSA: Yes 0-2
If you would like to speak to someone about your results, please click "Submit" below. Your information will not be shared with anyone and we will get in touch with you soon.
Submit
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