Sleep Assessment Questionnaire Sleep Assessment Questionnaire Please answer all questions to get accurate results. Your progress will be saved automatically. Epworth Sleepiness Scale (ESS) How likely are you to doze off in the following situations? (0 = Never, 3 = High chance) 1. Sitting and reading 0 1 2 3 2. Watching TV 0 1 2 3 3. Sitting, inactive in a public place (theatre, meeting, etc.) 0 1 2 3 4. As a passenger in a car for an hour without a break 0 1 2 3 5. In a car, while stopped for a few minutes in traffic 0 1 2 3 6. Lying down to rest in the afternoon when circumstances permit 0 1 2 3 7. Sitting quietly after lunch without alcohol 0 1 2 3 8. Sitting and talking to someone 0 1 2 3 STOP-BANG Questionnaire 1. Do you snore loudly (louder than talking or loud enough to be heard through closed doors)? Yes No 2. Do you often feel tired, fatigued, or sleepy during the daytime? Yes No 3. Has anyone observed you stop breathing during your sleep? Yes No 4. Do you have or are you being treated for high blood pressure? Yes No 5. Is your BMI more than 35 kg/m²? Yes No 6. Are you over 50 years old? Yes No 7. Is your neck circumference greater than 40 cm (16 inches)? Yes No 8. Are you male? Yes No OSA-50 Questionnaire 1. Do you snore loudly (louder than talking or loud enough to be heard through closed doors)? Yes No 2. Do you often feel tired, fatigued, or sleepy during the daytime? Yes No 3. Has anyone observed you stop breathing during your sleep? Yes No 4. Do you have or are you being treated for high blood pressure? Yes No 5. Is your BMI more than 35 kg/m²? Yes No Calculate Scores Clear Form Save Progress Load Saved
