Sleep Diagnostics

Sleep Assessment Questionnaire

Includes Epworth Sleepiness Scale and STOP-BANG screening.

NameEmailPhone

Epworth Sleepiness Scale

Rate your chance of dozing: 0 = none, 1 = slight, 2 = moderate, 3 = high.

Sitting and readingWatching televisionSitting inactive in a public placeAs a passenger in a car for an hour without a breakLying down to rest in the afternoonSitting and talking to someoneSitting quietly after lunch without alcoholIn a car, while stopped for a few minutes in traffic

STOP-BANG

Do you snore loudly?Do you often feel tired, fatigued or sleepy during the daytime?Has anyone observed you stop breathing during sleep?Do you have or are you being treated for high blood pressure?Is your BMI greater than 35 kg/m²?Are you older than 50?Is your neck circumference greater than 40 cm?Male sex? Additional sleep notes