Sleep assessment quiz

Take a sleep assessment quiz to see if you have sleep apnea and qualify for a sleep study.

Start the quiz

OR

You can download this form and bring it to your doctor for consultation and sign-off.

Download referral form

Epworth sleepiness scale (ESS)

How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just 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.

How likely are you to doze off in these situation	Never	Slight	Moderate	High
Sitting and reading	0	1	2	3
Watching television	0	1	2	3
Sitting inactive in a public place (e.g. a theatre or meeting)	0	1	2	3
As a passenger in a car for an hour without a break	0	1	2	3
Lying down to rest in the afternoon when circumstances permit	0	1	2	3
Sitting and talking to someone	0	1	2	3
Sitting quietly after a lunch without alcohol	0	1	2	3
In a car, while stopped for a few minutes in the traffic	0	1	2	3
Total score: 0

Next

Please select to complete STOP-BANG Questionnaire or OSA 50 Screening Questionnaire

STOP-BANG Questionnaire

Please answer Yes or No to the following questions	Yes	No
Do you snore loudly?	1	0
Do you often feel tired, fatigued, or sleepy during the daytime?	1	0
Has anyone observed you stop breathing during your sleep?	1	0
Do you have or are you being treated for high blood pressure?	1	0
Are you obese/very overweight - BMI more than 35 kg/m²?	1	0
Age over 50 years old?	1	0
Neck circumference greater than: 43cm (male) or 41cm (female)	1	0
Are you male?	1	0
Total score: 0

OSA 50 Screening Questionnaire

Please answer Yes or No to the following questions	Yes	No
Waist circumference Male > 120cm or Females > 88cm	3	0
Has your snoring ever bothered other people?	3	0
Has anyone noticed you stop breathing during your sleep?	2	0
Are you aged 50 years or over?	2	0
Total score: 0

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