Sleep Screen Test Step 1 of 4 25% Patient InformationNameAgeDOB MM slash DD slash YYYY HeightWeightNeck SizeBMI (calculated)Gender Male Female STOP BANG ScreenerSCORE: If you checked YES to two or more questions on the STOP portion you are at risk for OSA.Do you snore loudly? Yes No Do you feel fatigued during the day? Yes No Do you wake up feeling like you haven't slept? Yes No Have you been told you stop breathing at night? Yes No Do you gasp for air or choke while sleeping? Yes No Do you have high blood preassure or are you on medication to control high blood pressure? Yes No STOP BANG ScreenerSCORE: The more questions you checked YES to on the BANG portion, the greater your risk of having moderate to severe OSA. ** A score of 3 or more suggests high risk of OSA Is your body mass index greater than 35? Yes No Are you 50 years old or older? Yes No Are you a male with neck circumference greater than 17 inches, or a female with neck circumference greater than 16 inches? Yes No Are you a male? Yes No Epworth Sleepiness Scale Rate with 0-3 ScaleHow likely are you to doze off or fall asleep in the situations described below, in contrast to feeling just tired? This refers to your usual way of life in recent times. Even if you haven’t done some of these things recently, try to work out how they would have affected you. Use the following scale to choose the most appropriate number for each situation: 0 = Would never doze 1 = Slight chance of dozing 2 = Moderate chance of dozing 3 = High chance of dozing Sitting and Reading 0 1 2 3 Watching TV 0 1 2 3 Sitting inactive in a public place 0 1 2 3 (e.g. a theater or a meeting) Sitting in a car as a passenger for a continuous hour 0 1 2 3 Lying down to rest in the afternoon when circumstances permit 0 1 2 3 Sitting and talking to someone 0 1 2 3 Sitting quietly after lunch without alcohol 0 1 2 3 Sitting in a car stopped in traffic for a few minutes 0 1 2 3 Total Score0 - 9 Normal range 10 - 11 Borderline 12 - 24 Sleepy Sleep QuestionnaireTo be completed before patient's home sleep testNameStudy Date(Required) MM slash DD slash YYYY Time You Fell AsleepTypical Duration Of Sleep(Required)Current Medications(Required)Main sleep complaint Snorin Witnessed apnea (cessation of breath while sleeping) Excessive daytime sleepiness Other (explain in detail)Medical History(Required)
