Sleep symptom checklist
Based on the validated STOP-BANG screening questionnaire (Chung et al.). Check what applies, add up your checks, and bring this page to your visit. A screen is not a diagnosis — it's how the right conversation starts.
Part 1 — STOP
- ☐ Snoring — I snore loudly (louder than talking, or heard through a closed door)
- ☐ Tiredness — I'm often tired, fatigued, or sleepy during the daytime
- ☐ Observed — someone has seen me stop breathing, choke, or gasp in my sleep
- ☐ Pressure — I have, or am being treated for, high blood pressure
Part 2 — BANG
- ☐ BMI — my body mass index is over 35
- ☐ Age — I am over 50
- ☐ Neck — my neck measures more than 16 inches (40cm) around
- ☐ Gender — I am male
How to read your score
In the published screening: 0–2 total checks suggests lower risk; 3–4 intermediate; 5 or more, high risk of obstructive sleep apnea. Any "Observed" check is worth mentioning to a professional regardless of the total.
Notes for your visit
My bed partner says: ______________________________________________
I currently use / have tried a CPAP: ☐ Yes ☐ No — and it's going: ______________________
I wake up with: ☐ headaches ☐ dry mouth ☐ sore jaw ☐ none of these
Medications & conditions to mention: ______________________________
Dr. Abbey Dupay, DMD — Dupay Dentistry ·
3376 Woods Edge Cir, Ste 101, Bonita Springs, FL 34134 · (239) 498‑9666 · abbeydupay.com
Sleep apnea oral appliance therapy · a dentist can treat diagnosed OSA —
ask about it. Educational screening tool, not a diagnosis; diagnosis requires a physician-read sleep
study.