Do you have a history of snoring?
- Rarely – only once or a few times
- Sometimes – occasionally or under special circumstances
- Every night or almost every night
- Don’t know
Has your bed partner ever moved, temporarily or permanently to another bedroom (or had you move to another room) due to snoring or restless sleep? YES NO
Have you ever been told you seem to have momentary periods during sleep when you stop breathing or breathe abnormally? YES NO
Do you ever gasp for air during the night? YES NO
Have you ever been told you kick or make disruptive movements during sleep? YES NO
Do you have a family history of sleep apnea? YES NO
Epworth Sleepiness Scale
How likely are you to fall asleep in the following situations? In contrast to just feeling tired, this refers to your usual way of life in recent times. Even if you have not done some of the things recently, try to determine how the situation would affect you.
|0 = never doze||1 = slight chance||2 = moderate chance||3 = high chance|
|Situation:||Chance of dozing:|
|Sitting and reading||0||1||2||3|
|Sitting passive in a public place (ex. Theatre or meeting)||0||1||2||3|
|As a passenger in a car for an hour without a break||0||1||2||3|
|Lying down to rest in the afternoon when circumstances permit||0||1||2||3|
|Sitting and talking to someone||0||1||2||3|
|In a car while stopped for a few minutes in traffic||0||1||2||3|
Answer the following questions:
|Snore||Have you been told you snore?||Y||N|
|Tired||Are tired often during the day?||Y||N|
|Obstruction||Do you know if you stop breathing or has anyone witnessed you stop breathing while you are asleep?||Y||N|
|Pressure||Do you have high blood pressure or are you on medication to control high blood pressure?||Y||
If you answered YES to two or more questions on the STOP portion, you are at risk for obstructive sleep apnea. It is recommended that you contact your primary care provider to discuss a possible sleep disorder.
|BMI||Is your body mass index greater than 25?||Y||N|
|Age||Are you 50 years or older?||Y||N|
|Neck||Are you a male with a neck circumference greater than 17 inches, or a female with a neck circumference greater than 16 inches?||Y||N|
|Gender||Are you a male?||Y||N|
The more questions you answer YES to on the BANG portion, the greater your risk of having moderate to severe obstructive sleep apnea.
If you think you are risk for, or think you have, sleep apnea, please contact your primary care provider.