Free Risk Assessment

Sleep Apnea Screening Questionnaire

Note: An asterisk (*) indicates a required question.

This brief self-evaluation will help you and your doctor assess your risk for Obstructive Sleep Apnea (OSA). If the results suggest you may be at risk for a sleep disorder, we encourage you discuss them with your doctor for further evaluation.
Name*
What is your full name?
First Last
Phone
Please provide a nine-digit phone number where you can be reached for a follow-up.
Email*
Please enter an email address where we can send the results of this questionnaire when you complete it.

Epworth Sleepiness Scale
© M.W. Johns 1990-97, A new method for measuring daytime sleepiness: The Epworth Sleepiness Scale. Sleep 1991; 14(6):540-5.
How likely are you to doze off or fall asleep in the following situations, in contrast to just feeling tired?

This refers to your usual way of life in recent times.

Even if you have not done some of these things recently, try to work out how they would have affected you.

Use the following scale to choose the most appropriate number for each situation:
0 = would never doze
1 = slight chance of dozing
2 = moderate chance of dozing
3 = high chance of dozing
It is important that you answer each question as best you can.
Sitting and Reading*
What is the likelihood of you falling asleep while sitting and reading?
Watching TV*
What is the chance you might doze off while watching television?
Sitting in a Public Place*
Sitting, inactive in a public place (e.g. a theatre or a meeting)
As a Passenger in a Car*
As a passenger in a car for an hour without a break.
Lying Down to Rest*
Lying down to rest in the afternoon when circumstances permit.
Sitting and Talking*
Sitting and talking to someone.
Sitting Quietly After Lunch*
Sitting quietly after a lunch without alcohol.
In a Car, Stopped in Traffic*
In a car, while stopped for a few minutes in the traffic.
Click Submit to get an email with your results and some forms for your doctor
Calculated BMI
Your BMI is:
BMI > 30 [HIDDEN]
+1 on STOP-BANG if BMI > 30
STOP BANG Score
Out of a maximum score of 7 points, your STOP-BANG score is:
Epworth Sleepiness Score
Out of 8 questions with a maximum of 24 possible points, your score is:
Email
This field is for validation purposes and should be left unchanged.

Free Risk Assessment

Step 1 of 3

Sleep Apnea Screening Questionnaire

STOP-BANG Questionnaire

Epworth Sleepiness Scale

Click Submit to get an email with your results and some forms for your doctor