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Appointment Details

Services

Specialist Preferred

How likely is the patient to doze off or fall asleep in the following situations?

0 = would never fall asleep

1 = slight chance of falling asleep

2 = moderate chance of falling asleep

3 = high chance of falling asleep

Sitting and reading

Watching TV

Sitting, inactive in a public place (theatre, meeting, etc.)

As a passenger in a car for an hour without a break

In a car, while stopped for a few minutes in traffic

Sitting quietly after lunch without alcohol

Sitting and talking to someone

Lying down to rest in the afternoon when circumstances permit

STOP-BANG Questionnaire

Does the patient snore loudly (louder than talking or loud enough to be heard through closed doors)?

Does the patient often feel tired, fatigued, or sleepy during daytime?

Has anyone observed the patient stop breathing during their sleep?

Is the patient being treated for high blood pressure?

Body Mass Index more than 35 kg/m2?

Age: Is the patient over 50 years old?

Is the patients neck circumference greater than 40 cm?

Gender: Is the patient male?

First Name

Last Name

Phone

Birthday

Existing Patient *

Yes

Upload referral document

Upload File

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Reason for referral/history

Doctor's name

Provider number

Practice's name

Doctor's Contact

Date

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