Sleep Quality Questionnaire

Please have your patient fill out this questionnaire to help you assess the patients quality of sleep.

STOP-BANG Score is a tool used to screen patients for obstructive sleep apnea (OSA)
Do you snore loudly? (Louder than talking or loud enough to be heard through closed doors?) Do you often feel tired, fatigued, or sleepy during the daytime? Has anyone observed you stop breathing (apnea) during your sleep? Do you have, or are you being treated for high blood pressure? Is your Body Mass Index more than 35 kg/m2? If you dont know your BMI, list your weight ______ and height _____. Are you over 50 years old? Is your neck circumference over 40 cm or 16 inches? Is your gender male?

Yes Yes Yes Yes Yes

No No No No No

Yes No Yes No Yes No

______

Total number of YES answers

Results:  4-8 = Patient is a HIGH RISK for having OSA and should be referred to a sleep specialist 1-3 = Patient is at LOW RISK for having OSA 0 = Negative OSA screening

out of 8

Epworth Sleepiness Scale

How likely are you to doze off or fall asleep in the following situations?
Scale: 0 = would never doze 1 = slight chance of dozing 2 = moderate chance 3 = high chance Sitting and talking to someone Sitting inactive in a public place Sitting quietly after lunch without alcohol Sitting and reading Watching television Lying down to rest in the afternoon In a car while stopped in traffic As a passenger in a car

0 0 0 0 0 0 0 0
______

1 1 1 1 1 1 1 1

2 2 2 2 2 2 2 2

3 3 3 3 3 3 3 3

Add up total

out of 24

Results: 0-6 = Normal Range, 7-9 = Moderate Sleepiness, 10 or more = Abnormal Sleepiness (patient should be referred to a sleep specialist)

Additional Questions
Are you happy with your sleep? Does anyone complain about your sleep? Do you have trouble falling asleep, staying asleep or waking up too early? While lying in bed, do you experience leg discomfort or pains that can be relieved by movement?

Yes Yes Yes Yes

No No No No

The patient should be referred to a sleep specialist if there is a positive response to any of these questions.

1000 Alpine Ave. Suite 201 Boulder, CO 80304 | 303-938-5354 | Fax 303-524-3097 | bch.org/sleep