8/13/2019 SF SleepQualityQuestionnaire

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Sleep QualityQuestionnairePlease 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?) Yes No

Do you often feel tired, fatigued, or sleepy during the daytime? Yes No

Has anyone observed you stop breathing (apnea) during your sleep? Yes No

Do you have, or are you being treated for high blood pressure? Yes No

Is your Body Mass Index more than 35 kg/m2? Yes No

If you dont know your BMI, list your weight ______ and height _____.

Are you over 50 years old? Yes No

Is your neck circumference over 40 cm or 16 inches? Yes No

Is your gender male? Yes No

Total number of YES answers ______ out of 8

Results: 4-8 = Patient is a HIGH RISK for having OSA and should be referred to a sleep specialist1-3 = Patient is at LOW RISK for having OSA 0 = Negative OSA screening

Epworth Sleepiness ScaleHow 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 0 1 2 3

Sitting inactive in a public place 0 1 2 3

Sitting quietly after lunch without alcohol 0 1 2 3

Sitting and reading 0 1 2 3

Watching television 0 1 2 3Lying down to rest in the afternoon 0 1 2 3

In a car while stopped in traffic 0 1 2 3

As a passenger in a car 0 1 2 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 QuestionsAre you happy with your sleep? Yes No

Does anyone complain about your sleep? Yes No

Do you have trouble falling asleep, staying asleep or waking up too early? Yes No

While lying in bed, do you experience leg discomfort or pains that can be relieved by movement? Yes No

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

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