STOP-BANG Questionnaire Name * First Name Last Name Today's date MM DD YYYY 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 (BMI)? Greater than 35? * YES NO Age? Are you Aged older than 50? * YES NO Neck Circumference? Is your Neck size: For males: greater than 17 inches/43 cm? For females: greater than 16 inches/41 cm? (Measured around adams apple) * YES NO Is your Gender male? Males are considered to be more likely to have OSA. * YES NO Thank you! Complete our online form below or download a form to complete.
