The 2 Questionnaires below will assist in better understanding the need of a sleep test.
STOP-BANG Sleep Questionnaire
Are you at risk of Sleep Apnea?
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Date of Birth
*
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Do you snore loudly?
Please Select
Yes
No
Do you often feel tired/fatigued, or sleepy during the day?
Please Select
Yes
No
Has anyone noticed you stop breathing during sleep?
Please Select
Yes
No
Do you have or are you being treated for high blood pressure?
Please Select
Yes
No
Are you over 50 years of Age?
Please Select
Yes
No
Is your neck circumference bigger than 16 inches (female) or 17 inches (male)?
Please Select
Yes
No
Are you male?
Please Select
Yes
No
Is your Body Mass Index (BMI) more than 35? Calculate your BMI with our BMI tool.?
Please Select
Yes
No
BMI calculator
Total Score
Epworth Sleepiness Scale
How Likely are you to doze off or fall asleep in the following situations during the day? Use the following scale to choose the most appropriate number:
Sitting and reading
Please Select
0
1
2
3
Watching Television
Please Select
0
1
2
3
Sitting inactive, in a public place
Please Select
0
1
2
3
Lying down to rest in the afternoon when circumstances permit
Please Select
0
1
2
3
Sitting and talking to someone
Please Select
0
1
2
3
Sitting quietly after lunch without alcohol
Please Select
0
1
2
3
As a passenger in a car for an hour without a break
Please Select
0
1
2
3
In a car, while stopped for a few minutes in traffic
Please Select
0
1
2
3
Total
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