Sleep Questionnaire

Use this tool to determine if you are at risk for Obstructive Sleep Apnea.

1. Snoring: Do you snore loudly (louder than talking or loud enough to be heard through closed doors)?
Yes No

2. Tired: Do you often feel tired, fatigued, or sleepy during daytime?
Yes No

3. Observed: Has anyone observed you stop breathing during your sleep?
Yes No

4. Blood Pressure: Do you have or are you being treated for high blood pressure?
Yes No

5. Body Mass Index: BMI more than 35?
BMI = (Weight in Pounds / (Height in inches x Height in inches)) x 703
Yes No

6. Age: Age over 50 yr old?
Yes No

7. Neck Circumference: Neck circumference greater than 15 3/4 in (40 cm) around?
Yes No

8. Gender: Gender male?
Yes No

Adapted from STOP Questionnaire: A Tool to Screen Patients for Obstructive Sleep Apnea. Frances Chung, F.R.C.P.C., Balaji Yegneswaran, M.B.B.S., Pu Liao, M.D., Sharon A. Chung, Ph.D., Santhira Vairavanathan, M.B.B.S., Sazzadul Islam, M.Sc., Ali Khajehdehi, M.D., Colin M. Shapiro, F.R.C.P.C. Anesthesiology 2008; 108:812–21 Copyright © 2008, the American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins, Inc.