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Vocal Cord Dysfunction Questionnaire
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Menu
HOME
SERVICES
DOCTORS
INFORMATION
FAQ
Health Professionals
Patients
Publications
Webinars & Seminars
BLOG
FORMS & REFERRALS
Appointment Request Form
Lung Function Request Form
Sleep Study Request Form
Medical Review Referral Form
Patient Registration Form
Medical History
Epworth Sleepiness Scale
Stop-Bang Questionnaire
Asthma Control Questionnaire
Vocal Cord Dysfunction Questionnaire
CONTACT US
Appointment
Forms
STOP-BANG Sleep Apnea Questionnaire
FORMS
Fill all required fields (★) to submit the form.
Patient details:
Full Name:
(Required)
★ Title
Mr
Mrs
Ms
Miss
Other
Prefix
First
Last
Preferred name:
Date of birth:
(Required)
DD slash MM slash YYYY
Mobile Number
(Required)
Home Phone:
Address
Email Address:
(Required)
Height:
Weight:
Stop
1. Do you SNORE loudly (louder than talking or loud enough to be heard through closed doors)?
(Required)
1. Do you SNORE loudly (louder than talking or loud enough to be heard through closed doors)?
No
Yes
2. Do you often feel TIRED, fatigued, or sleepy during daytime?
(Required)
2. Do you often feel TIRED, fatigued, or sleepy during daytime?
No
Yes
3. Has anyone OBSERVED you stop breathing during your sleep?
(Required)
3. Has anyone OBSERVED you stop breathing during your sleep?
No
Yes
4. Do you have or are you being treated for high blood PRESSURE?
(Required)
4. Do you have or are you being treated for high blood PRESSURE?
No
Yes
Bang
5. BMI more than 35kg/m2?
(Required)
5. BMI more than 35kg/m2?
No
Yes
6. AGE over 50 years old?
(Required)
6. AGE over 50 years old?
No
Yes
7. NECK circumference > 16 inches (40cm)?
(Required)
7. NECK circumference > 16 inches (40cm)?
No
Yes
8. GENDER: Male?
(Required)
8. GENDER: Male?
No
Yes
Number of Yes:
Number of No:
Confirm:
(Required)
I acknowledge for the safety of others that I have provided true and accurate details and I agree that may details can be used for contact tracing.
(Required)
