SLEEP HABITS /  HISTORY

NAME:____________________

D.O.B:____

PATIENT PHONE NUMER:________________

STOP-BANG OSA screen

  1. Snoring:  Do you snore?  Yes   No
  2. Tired: Do you often feel tired, fatigued or sleepy during the daytime?  Yes  No
  3. Observed: Has anyone observed you stop breathing during your sleep?  Yes  No
  4. Blood Pressure: Do you have or are you being treated for high blood pressure?  Yes  No
  5. Weight:  BMI more than 35 kg/m2      Yes   No
  6. Age:  Are you over 50 years old?   Yes  No
  7. Neck Circumference: Is your neck circumference 40 cm? (16in)    Yes   No
  8. Gender:  Male    Yes  No

High risk of OSA: answering yes to three or more items
Low risk of OSA:  answering yes to less than three items

 

EPWORTH

Please indicate the chance of dozing in each situation using the scale below:

0 = no chance of dozing
1 = slight chance of dozing
2 = moderate chance of dozing
3 = high chance of dozing

SITUATION:

Sitting and reading:   (enter your chance of dozing to the right):_____
Watching TV: (enter your chance of dozing to the right):_____
Sitting inactive in a public place: (enter your chance of dozing to the right):_____
As a passenger in a car for an hour without a break: (enter your chance of dozing to the right):_____
Lying down to rest in the afternoon when circumstances permit: (enter your chance of dozing to the right):_____
Sitting and talking to someone: (enter your chance of dozing to the right):_____
Sitting quietly after a lunch without alcohol: (enter your chance of dozing to the right):_____
In a car, while stopped for a few minutes in traffic: (enter your chance of dozing to the right):_____
How many times do you get up at night? (enter your chance of dozing to the right):_____

ENTER TOTAL SCORE HERE:____

Signature of Patient or Parent of Minor: ________________________   Date:___________

(I attest that this information is true, accurate and complete to the best of my knowledge)

PDF VERSION OF THIS FORM HERE