STOP-BANG SCREEN

Screened on: [Date]
Patient: [Name or ID]
Setting: [Pre-surgery clinic, sleep clinic, primary care, hospital ward, or other]
Planned procedure: [Operation, date, and planned anesthesia, or none]
Form: [Version your service is licensed to use, language, and who asked the questions]

CRITERIA
Snoring: [Yes or no; reported by the patient or a bed partner]
Tiredness: [Yes or no]
Observed stopped breathing: [Yes or no; seen by whom, or no one sees them sleep]
High blood pressure: [Yes or no; diagnosed or treated, and today's reading]
BMI over 35: [Yes or no; measured height, weight, and BMI]
Age over 50: [Yes or no; age]
Neck at or over cutoff: [Yes or no; measured size in cm and the cutoff used]
Male sex: [Yes or no]

RESULT
STOP score: [Yes answers to the first four, 0 to 4]
Total: [0 to 8]
Risk level: [Low, intermediate, or high]
Rule applied: [Total alone, or STOP of 2 or more plus male sex, BMI over 35, or a large neck]

OTHER FINDINGS
Bloods and oxygen: [Serum bicarbonate, resting oxygen saturation]
Airway: [Mallampati class, mouth opening, jaw and neck movement]
Heart and lung disease: [Heart failure, pulmonary hypertension, lung disease, or none; controlled or not]
Sleepiness and driving: [Daytime sleepiness, any score used, and drowsy driving]

ACTIONS
Sleep testing: [Home sleep apnea test, in-lab study, sleep clinic referral, or none; date booked]
Anesthesia alert: [Who was told, when, and the precautions requested]
Positional and lifestyle advice: [Side sleeping, head of bed raised, evening alcohol, sedatives, weight]
CPAP: [Already uses one and brings it to hospital, or not applicable]
Patient told: [What was explained about the result and the next steps]
Screen again: [When, or what change would prompt it]

Recorded by: [Name, role]