Sleep Screening Questionnaire

Manse Medical's Sleep Screening Questionnaire

Please answer the following questions that relate to the Stop Bang Questionnaire and Epworth Sleepiness Scale to determine your sleep score.

Patient Information

First Name *

Surname *

Date of Birth *

Email Address *

Phone Number *

Gender

Height (centimeters)

Weight (kilograms)

Epworth Sleepiness Scale (ESS) Questions

Rate the following situations based on your likelihood of dozing off or falling asleep:

1) Sitting and reading *

0 - Never doze1 - Slight chance of dozing2 - Moderate chance of dozing3 - High chance of dozing

2) Watching TV *

0 - Never doze1 - Slight chance of dozing2 - Moderate chance of dozing3 - High chance of dozing

3) Sitting, inactive in a public place (e.g. theater or meeting) *

0 - Never doze1 - Slight chance of dozing2 - Moderate chance of dozing3 - High chance of dozing

4) As a passenger in a car for an hour without a break *

0 - Never doze1 - Slight chance of dozing2 - Moderate chance of dozing3 - High chance of dozing

5) Lying down to rest in the afternoon when circumstances permit *

0 - Never doze1 - Slight chance of dozing2 - Moderate chance of dozing3 - High chance of dozing

6) Sitting and talking to someone *

0 - Never doze1 - Slight chance of dozing2 - Moderate chance of dozing3 - High chance of dozing

7) Sitting quietly after a lunch without alcohol *

0 - Never doze1 - Slight chance of dozing2 - Moderate chance of dozing3 - High chance of dozing

8) In a car, while stopped for a few minutes in the traffic *

0 - Never doze1 - Slight chance of dozing2 - Moderate chance of dozing3 - High chance of dozing

Total score for Epworth Sleepiness Scale

A total score of 10 or more is considered indicative of excessive daytime sleepiness.

STOP-BANG Questionnaire Components

Answer Yes or No to the following questions:

1) Do you Snore loudly (louder than talking or loud enough to be heard through closed doors?

Yes No

2) Do you often feel tired, fatigued, or sleepy during daytime?

Yes No

3) Has anyone observed you stop breathing during your sleep?

Yes No

4) Do you have or are you being treated for high blood pressure?

Yes No

5) Is your BMI more then 35? To calculate your BMI = weight (kg) / [height (cm)]2 *

Yes No

6) Age over 50 years old?

Yes No

7) Neck circumference greater than 40 cm (15.75 inches)?

Yes No

8) Gender = Male?

Yes No

Total score for Stop Bang Questionnaire

A total score of 3 or more suggests a high risk of obstructive sleep apnea.

And we're done! These results will be emailed to you and Manse Medical. A team member will contact you within two business days to assist with your referral pathway.

I consent for Manse Medical to send marketing communication that may be relevant to me such as clinic updates, promotions and service information.I consent for Manse Medical to use the data provided in this questionnaire in an unidentifiable manner for research and development purposes.

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