Stop Bang & Epworth Sleepiness Form

Screening questionnaire for obstructive sleep apnoea

Patient Name *
Contact phone number *
Email address *
Referring Doctor *
Height (cm) *
Weight (kg) *
Age *
1. Snoring
Do you snore loudly (louder than talking or loud enough to be heard through closed doors)?
2. Tired
Do you often feel tired, fatigued, or sleepy during daytime?
3. Observed
Has anyone observed you stop breathing during your sleep?
4. Blood Pressure
Do you have or are you being treated for high blood pressure?
5. BMI
Is your BMI more than 35 kg/m2? (if unsure please leave black)
6. Age
Are you over 50 years old?
7. Neck Circumference
Is your neck circumference greater than 40 cm?
8. Gender
Are you male?
How likely are you to doze off or fall asleep in the situations described below, in contrast to feeling just tired? This refers to your usual way of life in recent times.
Situation Chance of dozing
Sitting and reading
Watching TV
Sitting, inactive in a public place (eg. a theatre or a meeting)
As a passenger in a car for an hour without a break
Lying down to rest in the afternoon when circumstances permit
Sitting and talking to someone
Sitting quietly after a lunch without alcohol
In a car, as the driver, while stopped for a few minutes in traffic
Additional Comments
* Required fields