Screening for Obstructive Sleep Apnea Download this form in PDF format First Name * Last Name * STOPAnswer the following questions to find out if you are at risk for Obstructive Sleep apnea. If you answered YES to two (2) or more questions on the STOP portion you are at risk for Obstructive Sleep Apnea. It is recommended that you contact your primary care provider to discuss a possible sleep disorder. S (snore) Have you been told that you snore? * Yes No T (tired) Are you often tired during the day? * Yes No O (obstruction) Do you know if you stop breathing or has anyone witnessed you stop breathing while you are asleep? * Yes No P (preasure) Do you have high blood pressure or on medication to control high blood pressure? * Yes No BANGTo find out if you are at moderate to severe risk of Obstructive Sleep Apnea, complete the BANG questions below. B (BMI) Is your body mass index greater than 28? * Yes No A (age) Are you 50 years old or older? * Yes No N (neck) Are you a male with a neck circumference greater than 17 inches, or a female with a neck circumference greater than 16 inches? * Yes No G (gender) Are you a male? * Yes No