Do you snore? Do you feel tired or sleepy during the day? Are you overweight or obese with a large neck? Do you have high blood pressure? These are some of the very simple screening questions in this very simple screening test for sleep apnea. What is sleep apnea? Sleep apnea literally means pauses in you breathing. It is a common disorder in which you have one or more pauses in breathing or shallow breaths while you sleep. Breathing pauses can last from a few seconds to minutes. They may occur 30 times or more an hour. Typically, normal breathing then starts again, sometimes with a loud snort or choking sound. Sleep apnea usually is a chronic medical condition that disrupts your sleep. When your breathing pauses or becomes shallow, you’ll often move out of deep sleep and into light sleep. As a result, the quality of your sleep is poor, which makes you tired during the day. Sleep apnea is a leading cause of excessive daytime sleepiness. Use this simple, easy to use, and quick screening test called STOP BANG to know your risk of sleep apnea. All you need is a tape to measure your neck, and knowledge of your basic medical history such as whether you take a blood pressure medicine (If you are not sure, you probably should not be reading this) What are the risks of untreated sleep apnea? Increase the risk of high blood pressure, heart attack, stroke, obesity, and diabetes Increase the risk of, or worsen, heart failure Make arrhythmias (ah-RITH-me-ahs), or irregular heartbeats, more likely Increase the chance of having work-related or driving accidents Sleep apnea is a chronic condition that requires long-term management. Lifestyle changes, mouthpieces, surgery, and breathing devices can successfully treat sleep apnea in many people. If you think you have sleep apnea and need help, W8MD Medical Weight Loss And Sleep Centers can not only help diagnose the problem with board certified physicians, but also can help potentially cure it in many situations with weight loss. We offer both home sleep studies and in the sleep lab polysomnographic, and CPAP titration studies. We have offices in many states in the United States and can help you We offer telemedicine and in person physician consultations with our board certified sleep and weight loss physicians. Call 1(800)W8MD-007 to learn more or visit http://www.w8md.com

1. Sleep Apnea Screening Questions
Were you ever diagnosed with sleep apnea? Yes No
If yes, do you currently use any treatment such as CPAP? Yes No
(If yes to both the above, please skip the rest of the form)
1. Snoring
Do you snore loudly?  Yes  No
2. Tired during the day
Do you often feel tired, fatigued or sleepy during daytime?  Yes  No
3. Observed Apneas
Has anyone observe you stopping breathing during your sleep?  Yes  No
4. Blood Pressure
Do you have or are you being treated for high blood pressure?  Yes  No
5. Body Mass Index -
BMI more than 35kg/m2
?  Yes  No
(If you do not know, let the doctor fill this for you)
6. Age -
Is your age over 50 years old? Yes  No
7. Neck circumference
Is your neck circumference greater than 40 cm? (16’’) Yes  No
(If you do not know, let the doctor fill this for you)
8. Gender
Are you male?  Yes  No
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Key: High risk of sleep apnea if you answered –’ Yes’ to three or more items
Low risk of sleep apnea if you answered – ‘Yes’ to less than three items
Please Fax This Form and a Prescription for any Sleep Studies to Sleep Medical Associates, PLLC
(718) 946-5502 or call us at (718) 946-5500. You can visit www.w8md.com for more information on
weight loss and sleep.