STOP-BANG Questionnaire

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Is it possible that you have ...
Obstructive Sleep Apnea (OSA)?

Please answer the following questions below to determine if you might be at risk.

Name *

Phone Number *

Snoring ?
Do you Snore Loudly (loud enough to be heard through closed doors or your bed-partner elbows you for snoring at night)? *

Yes

Tired ?
Do you often feel Tired, Fatigued, or Sleepy during the daytime (such as falling asleep during driving or talking to someone)?
*

Yes

Observed ?
Has anyone Observed you Stop Breathing or Choking/Gasping during your sleep?
*

Yes

Pressure ?
Do you have or are being treated for High Blood Pressure?
*

Yes

Body Mass Index

Do you have a BMI greater than 35 kg/m2?

Yes

Age

Are you older than 50 ?

Yes

Neck size large ? (Measured around Adams apple)
Is your shirt collar 16 inches / 40cm or larger?
*

Yes

Gender = Male ?
*

Yes

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