Sleep Apnea Screening Tools

First Name *

Last Name *

Date Of Birth *

Stop-Bang Questionnaire

The STOP-Bang Questionnaire is intended to give clinicians an easy-to-use tool to identify people who might have obstructive sleep apnea. The questionnaire consists of eight yes-or-no questions based on the major risk factors for OSA. The name STOP-Bang is an acronym for the first letter of each symptom or physical attribute often associated with OSA

Height

Weight

inchescm

lbkg

Snoring - Do you snore loudly (louder than talking or loud enough to be heard through closed doors? *

YesNo

Tired - Do you often feel tired, fatigued, or sleepy during daytime? *

YesNo

Observed - Has anyone observed you stop breathing during your sleep? *

YesNo

Blood Pressure - Do you have or are you being treated for high blood pressure? *

YesNo

BMI (practice staff can complete this)

BMI more than 35 kg/m2 ?

YesNo

*Practice Staff to complete

Age *

Age over 50? *

YesNo

Neck Circumference **Practice Staff can complete this

Greater than 40cm?

YesNo

Gender - Male? *

YesNo

Risk (practice staff to complete)

High risk is yes to 5-8 or more questions above

Intermediate risk is yes to 3-4 questions

Low risk is yes to less than three questions above

Medicare rebatable refferal needs yes to 3 or more

Adapted from the official STOP bang site

Epworth Sleepiness Scale

The ESS is a self-administered questionnaire with 8 questions. Respondents are asked to rate, on a 4-point scale (0-3), their usual chances of dozing off or falling asleep while engaged in eight different activities. Most people engage in those activities at least occasionally, although not necessarily every day.

Use the following scale to choose the most appropriate number for each situation. Even if you haven’t done some of these things recently, try to work out how they would have affected you. It is important that you answer each question as best you can

0 = would never doze

1 = slight chance of dozing

2 = moderate chance of dozing

3 = high chance of dozing

Total

For Clinic Use: Medicare Requirment for referral is a score of 8 or more AND 3 or more on STOP-Bang

0-5 = Lower normal daytime sleepiness
6-10 Higher nornmal daytime sleepiness
11-12 mild escess daytime sleepiness
13-15 Moderate excessive daytime sleepiness
16-24 Severe excessive daytime sleepiness

Adapted from the EES site