Please answer ALL of the following questions:
GENERAL
EYES
EARS, NOSE, MOUTH, THROAT
○ Yes ○ No
Change in appetite
○ Yes ○ No
Decreased vision
○ Yes ○ No
Hearing loss
○ Yes ○ No
Weight change
○ Yes ○ No
Blurred vision
○ Yes ○ No
Ear discharge
○ Yes ○ No
Weight loss
○ Yes ○ No
Double vision
○ Yes ○ No
Ear pain
○ Yes ○ No
Mood change
○ Yes ○ No
Flashing lights
○ Yes ○ No
Ringing in the ear
○ Yes ○ No
Pain
○ Yes ○ No
Seeing spots
○ Yes ○ No
Nasal discharge
○ Yes ○ No
Sleep changes
○ Yes ○ No
Discharge
○ Yes ○ No
Nasal obstruction
○ Yes ○ No
Night sweats
○ Yes ○ No
Dryness
○ Yes ○ No
Nose bleeds
○ Yes ○ No
Fever
○ Yes ○ No
Excessive tearing
○ Yes ○ No
Sinus pain
○ Yes ○ No
Chills
○ Yes ○ No
Irritation
○ Yes ○ No
Sinus/nasal congest
○ Yes ○ No
Dizziness
○ Yes ○ No
Itching
○ Yes ○ No
Mouth problems
○ Yes ○ No
Fatigue
○ Yes ○ No
Eye pain
○ Yes ○ No
Mouth sores
○ Yes ○ No
Weakness
○ Yes ○ No
Red eyes
○ Yes ○ No
Bleeding gums
CARDIOVASCULAR
RESPIRATORY
PSYCHIATRIC
○ Yes ○ No
Chest pain
○ Yes ○ No
Difficulty breathing
○ Yes ○ No
Anxiety
○ Yes ○ No
Chest pressure
○ Yes ○ No
Wheezing
○ Yes ○ No
Depression
○ Yes ○ No
Heart trouble
○ Yes ○ No
Chest congestion
○ Yes ○ No
Hallucinations
○ Yes ○ No
Heart murmur
○ Yes ○ No
Cough
○ Yes ○ No
Memory Loss
○ Yes ○ No
Lightheadedness
○ Yes ○ No
Phlegm/sputum
○ Yes ○ No
Nervousness
○ Yes ○ No
Palpitations
HEMATOLOGICAL/LYMPHATIC
○ Yes ○ No
Sadness
○ Yes ○ No
Leg cramps
○ Yes ○ No
Abnormal bleeding
○ Yes ○ No
Sleep problems
○ Yes ○ No
Edema
○ Yes ○ No
Abnormal bruising
○ Yes ○ No
Suicidal ideation
○ Yes ○ No
Abnormal glands
○ Yes ○ No
Tension /stress
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GASTROINTESTINAL
GENITOURINARY
INTEGUMENTARY
○ Yes ○ No Nausea
○ Yes ○ No Change in urination habits
○ Yes ○ No Change in skin color
○ Yes ○ No Vomiting
○ Yes ○ No Incontinence/leaking urine
○ Yes ○ No Itching
○ Yes ○ No Heartburn
○ Yes ○ No Urgency (have to go)
○ Yes ○ No Dry skin
○ Yes ○ No Change in stool consistency ○ Yes ○ No Night-time urination
○ Yes ○ No Hives
○ Yes ○ No Change in stool frequency
○ Yes ○ No Frequent urination
○ Yes ○ No Concern with spot
○ Yes ○ No Leaking stool
○ Yes ○ No Burning or pain on urination
○ Yes ○ No Lumps/masses
○ Yes ○ No Constipation
○ Yes ○ No Difficulty urinating
○ Yes ○ No Mole changes
○ Yes ○ No Diarrhea
○ Yes ○ No Reduced stream
○ Yes ○ No Open sores/wound
○ Yes ○ No Excessive belching
○ Yes ○ No Dribbling
○ Yes ○ No Painful skin
○ Yes ○ No Excessive flatulence (gas)
○ Yes ○ No Blood in urine
○ Yes ○ No
○ Yes ○ No Blood in the stool
○ Yes ○ No Pelvic pain
○ Yes ○ No Hair changes
○ Yes ○ No Rectal bleeding
○ Yes ○ No Change in menses (period)
○ Yes ○ No Nail changes
○ Yes ○ No Abdominal pain
○ Yes ○ No Menstrual irregularity
○ Yes ○ No Nipple discharge
MUSCULOSKELETAL
○ Yes ○ No Premenstrual syndrome
○ Yes ○ No Breast lump/mass
○ Yes ○ No Range of motion limitations
○ Yes ○ No Menopausal symptoms
○ Yes ○ No Breast pain
○ Yes ○ No Joint pain
○ Yes ○ No Bleeding after menopause
ENDOCRINE
○ Yes ○ No Muscle Pain
○ Yes ○ No Itching
○ Yes ○ No Chronic fatigue
○ Yes ○ No Stiffness
○ Yes ○ No Odor
○ Yes ○ No Excessive sweating
○ Yes ○ No Tenderness
○ Yes ○ No Genital sores
○ Yes ○ No Excessive thirst
○ Yes ○ No Neck pain
○ Yes ○ No Vaginal discharge
○ Yes ○ No Excessive urination
○ Yes ○ No Back pain
ALLERGIC / IMMUNOLOGIC
○ Yes ○ No Heat intolerance
○ Yes ○ No Difficulty reaching overhead
○ Yes ○ No Immune system problems
○ Yes ○ No Cold intolerance
○ Yes ○ No Falls
○ Yes ○ No Food/environment allergies
○ Yes ○ No Excessive wt. loss
○ Yes ○ No Difficulty walking
○ Yes ○ No Medication allergies
○ Yes ○ No Excessive wt. gain
○ Yes ○ No Difficulty rising from sitting
○ Yes ○ No Substance allergies
○ Yes ○ No Hair loss
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Rash
NEUROLOGICAL
○ Yes ○ No Numbness/Tingling
○ Yes ○ No Headaches
○ Yes ○ No Nerve Pain
○ Yes ○ No Migraines
○ Yes ○ No Paralysis
○ Yes ○ No Change in mental status
○ Yes ○ No Loss of muscle bulk
○ Yes ○ No Long term memory problems
○ Yes ○ No Muscles weakness
○ Yes ○ No Short term memory problems
○ Yes ○ No Involuntary movements
○ Yes ○ No Change in personality
○ Yes ○ No Tremors
○ Yes ○ No Confusion/disorientation
○ Yes ○ No Seizures
○ Yes ○ No Delusions
○ Yes ○ No Dizziness
○ Yes ○ No Trouble with coordination
○ Yes ○ No Fainting
○ Yes ○ No Handwriting change
○ Yes ○ No Vertigo
○ Yes ○ No Change in speech
○ Yes ○ No Focal weakness
○ Yes ○ No Difficulty with smelling
○ Yes ○ No Balance problems
○ Yes ○ No Change in taste
○ Yes ○ No Change in gait
Please list any other new or concerning symptoms here:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Name:__________________
STOP-BANG Questionnaire
This is a screening questionnaire for sleep apnea. Please answer yes or no to the following questions on the
front side of this page. The questions on the back of this page are for the physician or staff to complete. Thank
you for you cooperation.
***If you already have a diagnosis of sleep apnea, you do not need to complete this
questionnaire.
Yes
No
Snoring
Do you Snore Loudly (loud enough to be heard through closed doors or your
bed-partner elbows you for snoring at night)?
Yes
No
Tired
Do you often feel Tired, Fatigued, or Sleepy during the daytime (such as falling
asleep during driving or taking frequent naps)?
Yes
No
Observed
Has anyone Observed you Stop Breathing or Choking/Gasping during sleep?
Yes
No
Pressure
Do you have or are being treated for High Blood Pressure?
Yes
No
Body Mass Index more than 35kg/m2?
Yes
No
Age older than 50 years old?
Yes
No
Neck size large? (Measured around Adams apple)
For male, is your shirt collar 17 inches / 43 cm or larger?
For female, is your shirt collar 16 inches / 41 cm or larger?
Yes
No
Gender =Male
Score ________
Low risk of OSA: 0-2
Intermediate risk of OSA: 3-4
High risk of OSA: 5-8
Or 2 of 4 STOP + male
Or 2 of 4 STOP + BMI >35
Or 2 of 4 STOP + neck circumference 17in/43cm (male) or 16in/41cm (female)
Sleep apnea discussed _____
Sleep study ordered _____
or
Sleep study not clinically appropriate _____ or
Patient declined sleep study _____
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