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Sleep Screening Questionnaire

Date
Day
Month
Year

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

Birthday
Day
Month
Year
Gender
Male
Female
Prefer not to say

Rate the following situations based on your likelihood of dozing off or falling asleep: (choose one option only)

1) Sitting and reading
2) Watching TV
3) Sitting, inactive in a public place (e.g. theatre or meeting)
4) As a passenger in a car for an hour without a break
5) Lying down to rest in the afternoon when circumstances permit
6) Sitting and talking to someone
7) Sitting quietly after a lunch without alcohol
8) In a car, while stopped for a few minutes in the traffic

Total score for Epworth Sleepiness Score (Add up the ticked numbers)

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

STOP-BANG Questionaire 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 than 35 ?
Yes
No
Age over 50 years old ?
Yes
No
Neck circumference greater than 40cm (15.75 inches) ?
Yes
No
Gender at birth
Male
Female

Total number of times you replied 'Yes' :

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

These results will be emailed to you and Dr Tesfai.

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