Sleep Apnea Questionnaire

Sleep Apnea Questionnairestratweb2021-03-19T21:08:19-04:00

STOP-BANG Patient Questionnaire for Sleep Apnea

Sleep apnea is is a disorder which causes your breathing to pause while you are sleeping. If left untreated, sleep apnea will harm your heart. It can weaken your immune system, increase weight gain, lower your energy level, and reduce your quality of life, in most cases. It can also increase your risk for breathing problems after any surgery.

Your answers to this sleep apnea questionnaire will tell us if we need to take special steps for your safety and heart health while in our care. Your provider will discuss your questionnaire score with you and may ask you to see a sleep physician or specially trained Nurse Practitioner.

In general, 3 or more “Yes” answers indicate a higher risk of sleep apnea.

Required fields are indicated by an asterisk (*)

Patient's Name*
First Last
Snoring: Do you snore loudly (louder than talking or loud enough to be heard through closed doors)?*
- Yes
- No
Tiredness/Fatigue: Do you often feel tired, fatigued, or sleepy during the daytime, even after a “good” night’s sleep?*
- Yes
- No
Observed Apnea: Has anyone ever observed you stop breathing during your sleep?*
- Yes
- No
Pressure: Do you have or are you being treated for high blood pressure?*
- Yes
- No
Body Mass Index: Do you weigh more for your height than shown in the height/weight table below?*
- Yes
- No

Table 1. Height/Weight

HEIGHT / WEIGHT	HEIGHT / WEIGHT	HEIGHT / WEIGHT	HEIGHT / WEIGHT
4' 10" - 166	5' 3" - 196	5' 8" - 229	6' 1" - 264
4' 11" - 172	5' 4" - 203	5' 9" - 235	6' 2" - 271
5' 0" - 178	5' 5" - 209	5' 10" - 242	6' 3" - 278
5' 1" - 184	5' 6" - 215	5' 11" - 249	6' 4" - 286
5' 2" - 190	5' 7" - 222	6' 0" - 257	6' 5" - 293

Age: Are you older than 50 years?*
- Yes
- No
Neck Size: Does your neck measure more than 16 inches (41 cm) around if you are a female or 17 inches (43 cm) around if you are a male?*
- Yes
- No
Gender: Are you male?*
- Yes
- No
Total number of "Yes" answers*
Count how many times you answered "Yes." Then select that number below.
STOP-BANG Patient Questionnaire used with permission, F. Chung 2012
Notes:
- Weights greater than those shown correspond to a BMI of 35 or greater.
- Table from: nhibi.nih.gov/guidelines/obesity/bmi_tbl.htm.
- Calculations from http://www.nhlbisupport.com/bmi.
For general populations:
- Low risk of Sleep Apnea: 0-2 "Yes" answers
- Intermediate risk of Sleep Apnea: 3-4 "Yes" answers
- High risk of Sleep Apnea: 5-8 "Yes" answers OR Yes to 2 or more of 4 STOP questions + male gender OR Yes to 2 or more 4 STOP questions + Yes to #5 OR Yes to 2 or more of 4 STOP questions + Yes to #7
Propriety to University Health Network. www.stopbang.ca. Modified from Chung F et al. Anesthesiology 2008; 108:812-21; Chung F et al. Br J Anaesth 2012, 108:768-75; Chung F et al. J Clin Sleep Med 2014; 10-951-8.
Consent*
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Sleep Apnea Questionnaire

STOP-BANG Patient Questionnaire for Sleep Apnea

Table 1. Height/Weight

Notes:

For general populations: