STOP-BANG Questionnaire

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Your name *

Snoring

Do you Snore Loudly (loud enough to be heard through closed doors or your bed-partner elbows you for snoring at night)?

Yes

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Tired?

Do you often feel Tired, Fatigued, or Sleepy during the daytime (such as falling asleep during driving or talking to someone)?

Yes

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Observed?

Has anyone Observed you Stop Breathing or Choking/Gasping during your sleep?

Yes

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Pressure?

Do you have or are being treated for High Blood Pressure?

Yes

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Steps to calculate BMI:

1.Multiply your weight in lbs by 0.45
2.Multiply your height in inches by 0.025
3.Square the answer from step 2.
4.Divide the answer from step 1 by the answer in step 3.

Body Mass Index more than 35 kg/m2?

Yes

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Age older than 50 year old?

Yes

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Neck size large? (Measured around Adams apple)For male, is your shirt collar 17 inches/43 cm or larger? For female, is yourshirt collar 16 inches/41 cm or larger?

Yes

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Gender: Male?

Yes

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Scoring Criteria: For general populationLow risk of OSA: Yes to 0-2 questions Intermediate risk of OSA: Yes to 3-4 questions High risk of OSA: Yes to 5-8 questionsor Yes to 2 or more of 4 STOP questions + male genderor Yes to 2 or more of 4 STOP questions + BMI > 35 kg/m2or Yes to 2 or more of 4 STOP questions + neck circumference (17”/43cm in male, 16”/41cm in female)

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This form was created inside of Midtown Orthodontics.