Screening

STOP-BANG Sleep Apnea Screening

1 page12 fieldsHIPAA-ready

Form preview

formisoft.com/f/stop-bang-sleep-apnea
Patient Name
Date of Birth
Do you Snore loudly?
Do you often feel Tired during the day?
Has anyone Observed you stop breathing during sleep?
Are you treated for high Blood Pressure?
BMI greater than 35?
Age over 50 years?
Neck circumference greater than 40 cm?
Gender
Select...
STOP-BANG Total Score
OSA Risk Level
Select...
Submit

The STOP-BANG Sleep Apnea Screening form digitizes one of the most widely validated and easy-to-administer screening tools for obstructive sleep apnea (OSA). The acronym represents eight risk factors: Snoring loudly, feeling Tired during the day, Observed apnea during sleep, high blood Pressure, BMI over 35, Age over 50, Neck circumference over 40 cm, and male Gender. Each item is scored as yes (1) or no (0), producing a total score from 0 to 8.

Risk stratification is straightforward: a score of 0-2 indicates low risk for OSA, 3-4 indicates intermediate risk, and 5-8 indicates high risk. Studies have shown the STOP-BANG has a sensitivity exceeding 90% for detecting moderate-to-severe OSA, making it an excellent first-line screening tool. The digital form includes fields for the score and provides risk-level interpretation, along with recommendations for further evaluation such as home sleep testing or in-lab polysomnography.

This template is widely applicable across clinical settings including pre-operative anesthesia assessments (where undiagnosed OSA poses significant surgical risk), primary care practices evaluating patients with hypertension or metabolic syndrome, sleep medicine referral workflows, and occupational health programs screening commercial drivers or pilots. The STOP-BANG is endorsed by the American Society of Anesthesiologists and the American Academy of Sleep Medicine as a validated OSA screening instrument.

What's included

  • All eight validated STOP-BANG screening items
  • Automatic score calculation and risk stratification
  • OSA risk-level interpretation (low, intermediate, high)
  • Recommendations for further sleep testing
  • BMI and neck circumference measurement fields
  • Provider notes and referral documentation

Who uses this template

  • Pre-operative anesthesia sleep apnea risk assessment
  • Primary care screening for patients with hypertension or obesity
  • Sleep medicine referral and triage workflows
  • Occupational health screening for safety-sensitive positions

All form fields

12 fields across 1 page. Customize any field after signing up.

Patient NameText
Date of BirthDate
Do you Snore loudly?Multiple Choice
Do you often feel Tired during the day?Multiple Choice
Has anyone Observed you stop breathing during sleep?Multiple Choice
Are you treated for high Blood Pressure?Multiple Choice
BMI greater than 35?Multiple Choice
Age over 50 years?Multiple Choice
Neck circumference greater than 40 cm?Multiple Choice
GenderDropdown
STOP-BANG Total ScoreNumber
OSA Risk LevelDropdown

Use this template

Sign up and start customizing the STOP-BANG Sleep Apnea Screening for your practice. 30-day money-back guarantee.

$79.99/mo · Cancel anytime · HIPAA compliant

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