Epworth Sleepiness Scale/STOP-BANG Questionnaire
Today's Date
*
-
Month
-
Day
Year
Date
Patient Name
*
First Name
Last Name
Please rate these situations associated with sleepiness:
No chance of dozing - 0:
Slight chance of dozing - 1:
Moderate chance of dozing - 2:
High chance of dozing - 3:
Sitting and reading:
Watching television:
Sitting inactive in a public space:
Sitting for an hour as a passenger in a car:
Lying down in the afternoon to rest:
Sitting and talking to another person:
Sitting quietly after a lunch (no alcohol at lunch):
Sitting in a car, stopped for a few minutes due to traffic:
Epworth Sleepiness Scale Total score:
Add the number of points indicated in the column above for each row.
Please answer the following questions:
*
No - 0
Yes - 1
1. Do you
S
nore loudly?
2. Do you often feel
T
ired, fatigued, or sleepy during the daytime?
3. Has anyone
O
bserved you stop breathing during sleep?
4. Do you have (or have you been treated) for high blood
P
ressure?
5. Are you male or were you assigned the male sex at birth?
6. Are you over the age of 50?
MAs: Please score each column:
No - 0
Yes - 1
7. Is the patient's BMI over or equal to 35 kg/m2?:
8. Does the patient have a neck circumference of equal to or greater than 40 cm/15.75 inches? (If unknown, select no, but try to determine this from picture and/or BMI)
STOP-BANG Questionnaire Total Score
Add 1 point for every "yes" answer in questions 1-8 above.
References
1. Johns MW. A new method for measuring daytime sleepiness: the Epworth Sleepiness Scale. Sleep. 1991;14(6):540-545. 2. Modified from Chung F et al. Anesthesiology 2008; 108: 812-821, Chung F et al Br J Anaesth 2012; 108: 768-775, Chung F et al J Clin Sleep Med Sept 2014.
MA Instructions:
File as: TESTING REPORT with this title: Epworth - Score: #; STOPBANG - Score: # Then send a message to the provider, "Please see the attached Epworth/STOPBANG test. Advise Cora if the patient should proceed with the sleep ring study."
Submit Survey
Should be Empty: