Sleep Apnea Evaluation Form2

Is it possible that you have Obstructive Sleep Apnea (OSA)?
Please answer the following questions below to determine if you might be at risk.

Your Name (required)

Your email (required)

Telephone

DOB

Sex
MaleFemale

City

Family Physician

STOP

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

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

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

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

Bang

Body Mass Index more than 35 kg/m^2? BMI Calculator
YesNo

Age older than 50?
YesNo

Neck size large? (Measure around Adams apple)
Is your shirt collar 16 inches / 40cm or larger?
YesNo

Gender = Male?
YesNo

For general population
Please check what relates to you:
OSA – Low Risk: Yes to 0 – 2 questionsOSA – Intermediate Risk: Yes to 3 – 4 questionsOSA – High Risk: Yes to 5 – 8 questionsor Yes to 2 or more of 4 STOP questions + male genderor Yes to 2 or more of 4 STOP questions + BMI > 35kg/m2or Yes to 2 or more of 4 STOP questions + neck circumference 16 inches / 40 cm

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Property of University Health Network, available at http://www.stopbang.ca/osa/screening.php
Modified from:
Chung F et al. Anesthesiology 2008; 108: 812-821,
Chung F et al Br J Anaesth 2012; 108: 768-775,
Chung F et al J Clin Sleep Med Sept 2014.
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The results of this test may indicate that you are experiencing sleep apnea. At your request this information can be sent to your physician.
I hereby confirm that all of the above information is correct and complete, and authorize Pacific Sleep Care to release any part or all of this information to my physician(s).
Pacific Sleep Care agrees to keep your information confidential.