Evaluate Your Sleep | Sleep Disorders Service of New York

Sleep Apnea Screening
Stop Bang
Body Mass Index (BMI) Calculator
Sleepiness Scale
Restless Legs

Medical Problems

Heart disease or history of heart surgery

High blood pressure (even if effectively treated w/medications)

Neurological problems or chronic headaches.

Chronic lung disease or active smoking

Attention Deﬁcit Disorder or Chronic Fatigue Syndrome or Fibromyalgia or Depression

Chronic use of sleeping pills or narcotic pain medications

Physical Findings

Obesity or enlarged neck

Small mouth/ throat including enlarged tonsils

Chronic leg swelling

Signs or Symptoms

Motor vehicle accident or sleepiness while driving

Witnessed pauses in breathing during sleep

Loud Snoring

Heartburn/ acid reﬂux or waking with a dry mouth or throat

Frequently awakening tired or difﬁculty concentrating

Awakening more than 2 times per night or Insomnia

Prefer to avoid sleeping on your back

Sleepwalking as an adult or prominent dreaming

Answer the following questions to find out if you are at risk for Obstructive Sleep apnea.

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 (pressure) Do you have high blood pressure or on medication to

control high blood pressure?

Yes

No

To 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

Body Mass Index (BMI) Categories:

Underweight = BMI of <18.5 kg/m²
Normal weight = BMI of 18.5-24.9 kg/m²
Overweight = BMI of 25-29.9 kg/m²
Obesity = BMI of 30-34.9 kg/m² (Increased risk of sleep apnea)
Significant Obesity= BMI of 35 kg/m² or greater (Substantially increased risk of sleep apnea)

Your Height:

(feet)

(inches)

Your Weight:

(pounds)

kg/m²

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. Use the following scale to choose the most appropriate number for each situation:

You do not have significant daytime sleepiness.

You have minimal daytime sleepiness.

You have significant daytime sleepiness.

You should consider seeing a sleep specialist

Scale

0 = No chance of dozing
1 = Slight chance of dozing
2 = Moderate chance of dozing
3 = High chance of dozing

Epworth Sleepiness Scale

Sitting and Reading
Watching TV
Sitting inactive in a public place (e.g. theater or a meeting)
As a passenger in a car for an hour without a break
Lying down to rest in the afternoon when the circumstances permit
Sitting and talking to someone
Sitting quietly after lunch without alcohol
In a car, while stopped for a few minutes in traffic
Total:

0-9= Normal
10-14=Mild
15-18=Moderate
19-24=severe

SEVERITY SCALE

31-40=Very severe
21-30=Severe
11-20=Moderate
1-10=Mild
0=None

Overall, how would you rate the RLS discomfort in you legs or arms?

Very severe

Severe

Moderate

Mild

None

Overall, how would you rate the need to move around because of your RLS symptoms?

Very severe

Severe

Moderate

Mild

None

Overall, how much relief of your RLS arm or leg discomfort do you get from moving around?

No relief

Slight relief

Moderate relief

Either complete or almost complete relief

No RLS symptoms and therefore question does not apply

Overall, how severe is your sleep disturbance from your RLS symptoms?

Very severe

Severe

Moderate

Mild

None

How severe is your tiredness or sleepiness from your RLS symptoms?

Very severe

Severe

Moderate

Mild

None

Overall, how severe is your RLS as a whole?

Very severe

Severe

Moderate

Mild

None

How often do you get RLS symptoms?

Very severe (This means 6 to 7 days a week.)

Severe (This means 4 to 5 days a week.)

Moderate (This means 2 to 3 days a week.)

Mild (This means 1 day a week or less.)

None

When you have RLS symptoms, how severe are they on an average day?

Very severe (This means 8 hours per 24 hour day or more.)

Severe (This means 3 to 8 hours per 24 hour day.)

Moderate (This means 1 to 3 hours per 24 hour day.)

Mild (This means less than 1 hour per 24 hour day.)

None

Overall daily affairs, how severe is the impact of your RLS symptoms on your ability to carry out your ,for example carrying out a satisfactory family, home, social, school, or work life?

Very severe

Severe

Moderate

Mild

None

How severe is your mood disturbance from your RLS symptoms–for example angry, depressed, sad,anxious, or irritable?

Very severe

Severe

Moderate

Mild

None

Medical Problems

Physical Findings

Signs or Symptoms

Body Mass Index (BMI) Categories:

Scale

Epworth Sleepiness Scale

SEVERITY SCALE

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