patient referral form stop-bang questionnaire a tool to screen for obstructive sleep apnea snoring...
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WWW.THESNORESHOP.CA
Physician:
Physician Signature:
Date:
PATIENT REFERRAL FORM
** PLEASE AFFIX PATIENT LABEL IF AVAILABLE **
Name:
Address:
PHONE NUMBERS
Home: Work:
Cell:
Date of Birth: DD / MM / YY
Reason for Referral:
Assess for OSA
Other (symptoms):
REQUESTED SERVICE
Please note the Home Sleep Study is FREE of charge
Home Sleep Study
CPAP Trial
Sleep well, feel well.
Snore Shop Charlottetown161 St. Peters RoadCharlottetown, PE C1A 5P6Tel: 902-367-6374Fax: [email protected]
Snore Shop Summerside61 Central StreetSummerside, PE C1N 3L2Tel: 902-367-6374Fax: [email protected]
WWW.THESNORESHOP.CA
STOP-BANG QUESTIONNAIREA tool to screen for Obstructive Sleep Apnea
SNORINGDo you snore loudly (louder than talking or loud enough to be heard through closed doors)? YES NO
TIREDDo you often feel tired, fatigued or sleepy during the daytime? YES NO
OBSERVEDHas anyone observed you stop breathing during your sleep? YES NO
BLOOD PRESSUREDo you have or are you being treated for high blood pressure? YES NO
BMIBMI more than 35kg/m2? YES NO
AGEAge over 50 years old? YES NO
NECK CIRCUMFERENCENeck circumference greater than 40cm / 16”? YES NO
GENDERGender - Male? YES NO
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STOP-Bang Scoring Model
Chung F., et al
"YES" to three or more items indicates a high risk of OSA.
"YES" to less than three items indicates a low risk of OSA.