Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
STOP-BANG Sleep Apnea Screening
Your information
Patient Name *
Date of Birth
____ / ____ / ________
Do you Snore loudly?
- Yes
- No
- Not sure
Do you often feel Tired during the day?
- Yes
- No
- Not sure
Has anyone Observed you stop breathing during sleep?
- Yes
- No
- Not sure
Are you treated for high Blood Pressure?
- Yes
- No
- Not sure
Additional details
BMI greater than 35?
Age over 50 years?
Neck circumference greater than 40 cm?
Gender
STOP-BANG Total Score
OSA Risk Level
STOP-BANG Sleep Apnea Screening template from formisoft.com. formisoft.com/intake-templates/stop-bang-sleep-apnea