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reception@swcpc.com.au
Suite 2.12, 90 Podium Way, Oran Park New South Wales 2570, Australia
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OurTeam
Dr Saurabh Gupta
Dr Haider Naqvi
Dr Shervin Amirmalek
Dr Michelle Donegan
Shondell Tilden
Services
Respiratory
Respiratory Function Testing
Sleep
Home Based Sleep Studies
Mandibular Advancement Splint (MAS) Consultation
Patients Resources
Practitioner Resources
Contact Us
Menu
Home
OurTeam
Dr Saurabh Gupta
Dr Haider Naqvi
Dr Shervin Amirmalek
Dr Michelle Donegan
Shondell Tilden
Services
Respiratory
Respiratory Function Testing
Sleep
Home Based Sleep Studies
Mandibular Advancement Splint (MAS) Consultation
Patients Resources
Practitioner Resources
Contact Us
(02) 4607 5010
SLEEP APNOEA QUESTIONNAIRE
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Patient Name
*
Address
Address Line 1
City
State / Province / Region
Postal Code
Email
*
Phone
*
StopBang Questionnaire
1. Do you SNORE loudly? Loud enough to be heard through closed doors.
Yes
No
2. Do you often feel TIRED, fatigued, or sleepy during the day?
Yes
No
4. Do you have or are being treated for high blood PRESSURE?
Yes
No
afternoon resting an
Height (cm)
Weight (kg)
5. BMI more than 35?
Yes
No
6. AGE over 50 years old?
Yes
No
7. NECK circumference >40cm = ______cm
Yes
No
8. GENDER
M
F
OSA 50 Questionnaire
Obesity: Waist circumference* Males >102cm Females>88cm
Yes
No
*Waist circumference measured at umbilical level
3pts
Snoring: Has your snoring bothered people?
Yes
No
3pts
Apnoea’s: Has anyone noticed that you stop breathing during your sleep?
Yes
No
2pts
50: Are you aged 50 years or over?
Yes
No
2pts
Epworth Sleepiness Scale
Use the following scale to choose the most appropriate number for each situation:
0= Would NEVER doze
1=SLIGHT chance of dozing
2=MODERATE chance of dozing
3=HIGH chance of dozing
Sitting and reading
0
1
2
3
Watching TV
0
1
2
3
Sitting, inactive in a public place (e.g., 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 resting in the afternoon when the circumstances permit
0
1
2
3
Siting and talking to someone
0
1
2
3
Sitting quietly after lunch
0
1
2
3
In a car, while stopped for a few minutes in the traffic
0
1
2
3
Submit
