Sleep & Airway Group
Adult STOP-BANG Sleep Questionnaire

Name *

First Name

Last Name

Phone *

(###)

###

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Snoring?

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

Yes

No

Tired?

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

Yes

No

Observed?

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

Yes

No

Pressure?

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

Yes

No

Body

Body Mass Index more than 35 lb/in2? Calculate your BMI here: https://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmicalc.htm

Yes

No

Age

Older than 50?

Yes

No

Neck

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

Yes

No

Gender

Are you male?

Yes

No