RSDC | STOP-BANG Sleep Apnea Questionnaire

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HOME
SERVICES
DOCTORS
INFORMATION
FORMS & REFERRALS
CONTACT US
Online Appointment

Online Appointment

online Appointment

Home-Based Sleep Study Online booking

Step2

In this step you will be qualified to attend the home-based sleep study, your score should be more than 3.

Forms

STOP-BANG Sleep Apnea Questionnaire

FORMS

Fill all required fields (★) to submit the form.

Patient details:

Full Name:(Required)

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

For calculating your BMI, click here

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)

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admin@rsdc.au
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