STOP-BANG QUESTIONNAIRE

Patient Name: *

First

Last

Email *

Phone *

Date

Office *

1. Have you been told you snore loudly (louder than talking or loud enough to be heard through closed doors?) *

2. Do you often feel tired during the daytime? *

3. Has anyone ever observed you stop breathing while sleeping? *

4. Do you have or are you being treated for high bloodpressure? *

MEDICATION:

5. Height *

Weight *

BMI *

6. Is your age over 50? *

Age:

7. Neck circumference greater than 40 cm/16 inches? *

8. Gender male? *

Questions or Comments

Providing the highest quality dental care which achieves the optimum dental health possible for every patient.