Repulse Bay Office
STOP-BANG Sleep Apnea Questionnaire
Personal Information
Patient Name*
Height*
Weight*
Age*
STOP
Yes
No
Do you
S
NORE loudly (louder than talking or loud enough to be heard through closed doors)?
Do you often feel
T
IRED, fatigued, or sleepy during daytime?
Has anyone
O
BSERVED you stop breathing during your sleep?
Do you have or are you being treated for high blood
P
RESSURE?
BANG
Yes
No
B
MI more than 35kg/m2?
A
GE over 50 years old?
N
ECK circumference > 16 inches (40cm)?
G
ENDER: Male?
Total Score:
0
High risk of OSA: Yes
5-8
Intermediate risk of OSA: Yes
3-4
Low risk of OSA: Yes
0-2
