STOP-BANG Questionnaire V3 - NovaSom€¦ · Microsoft Word - STOP-BANG Questionnaire V3.docx...
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STOPBANG Obstructive Sleep Apnea (OSA) Questionnaire Please Print, Complete & Share with your Health Care Professional. 1. ANSWER EACH QUESTION BELOW. STOP Do you S NORE loudly (louder than talking or loud enough to be heard through closed doors)? Yes No Do you often feel T IRED, fatigued, or sleepy during daytime? Yes No Has anyone O BSERVED you stop breathing during your sleep? Yes No Do you have or are you being treated for high blood P RESSURE? Yes No BANG B MI more than 35g/m 2 Yes No A GE over 50 years old? Yes No N ECK circumference > 15.75 inches (40cm)? Yes No Male G ENDER? Yes No 2. CALCULATE YOUR OBSTRUCTIVE SLEEP APNEA (OSA) RISK ≥ 3 "Yes" answers = HighRisk for OSA < 3 "Yes" answers = Lowrisk for OSA TOTAL SCORE Yes = ______ No = _______ 3. IF AT HIGHRISK, TALK TO YOUR HEALTH CARE PROFESSIONAL TODAY! And discuss the AccuSom Home Sleep Test, provided by NovaSom, for testing in the comfort of your own bed. Name: Address: Height: Weight: Age: Male/Female:
Transcript of STOP-BANG Questionnaire V3 - NovaSom€¦ · Microsoft Word - STOP-BANG Questionnaire V3.docx...
STOP-‐BANG Obstructive Sleep Apnea (OSA) Questionnaire
Please Print, Complete & Share with your Health Care Professional.
1. ANSWER EACH QUESTION BELOW.
STOP
Do you SNORE loudly (louder than talking or loud enough to be heard through closed doors)?
Yes No
Do you often feel TIRED, fatigued, or sleepy during daytime?
Yes No
Has anyone OBSERVED you stop breathing during your sleep?
Yes No
Do you have or are you being treated for high blood PRESSURE?
Yes No
BANG BMI more than 35g/m2 Yes No
AGE over 50 years old? Yes No
NECK circumference > 15.75 inches (40cm)? Yes No
Male GENDER? Yes No
2. CALCULATE YOUR OBSTRUCTIVE SLEEP APNEA (OSA) RISK ≥ 3 "Yes" answers = High-‐Risk for OSA < 3 "Yes" answers = Low-‐risk for OSA
TOTAL SCORE Yes = ______ No = _______ 3. IF AT HIGH-‐RISK, TALK TO YOUR HEALTH CARE PROFESSIONAL TODAY!
And discuss the AccuSom Home Sleep Test, provided by NovaSom, for testing in the comfort of your own bed.
Name: Address: Height: Weight: Age: Male/Female:
