STOP-BANG

Date

Please complete your personal information below.

First Name *

First

Last Name *

Last

Email

Phone *

Date of birth *

Gender *

M

F

Are you an existing patient? *

Yes

No

For each question below, please select either Yes or No.

Snoring - Do you snore loudly? (louder than talking or can be heard through closed doors) *

Yes

No

Tired - Do you often feel tired, fatigued, or sleepy during the daytime? *

Yes

No

Observed - Has anyone observed you stop breathing during your sleep? *

Yes

No

Pressure - Do you have or are you being treated for high blood pressure? *

Yes

No

BMI - Do you have a body mass index of more than 35kg/m²? *

Yes

No

Age - Are you aged older than 50 years? *

Yes

No

Neck - Is your neck circumference greater than 43cm for a male and 41cm for female? *

Yes

No

Gender = Male? *

Yes

No