Go to Q6a Q5b Is your sugar well controlled? Yes No Q6a Have you had or are you treated for fits or No Yes blackouts? Go to Q7a Q6b Have you had tests and are the results known? Yes No Q6c Are the symptoms well controlled? Yes No Q7a Have you had or are you treated for: Excessive bleeding or bruising? No Yes Blood clots (DVT or PE)? No Yes Do you take blood thinning medicine (eg Aspirin, warfarin, clopidogrel etc)? No Yes Q7b Have you had: A stroke /TIA (mini Stroke) in the last 3 months? No Yes A recent DVT or PE? No Yes Cardiac stents in the last year? No Yes Go to Q8a No Yes Q8a Do you have a pacemaker or other implantable device? Go to Q9 Q8b Has the device been checked in the last year? Yes No Q9a Do you have any allergies? No Yes (Medicines, foods, latex etc) Go to Q10 Q9b If yes, do you suffer Nausea or vomiting or swelling A rash Q10a Have you ever been diagnosed with Obstructive No Yes & I use Yes but I Sleep Apnoea Syndrome (OSAS)? Go to treatment do not use Q10b (eg CPAP) treatment Q10b S: SNORING Do you snore loudly enough to be No Yes heard through closed doors? T: Do you feel tired in the daytime No Yes every day? O: OBSERVED Has anyone seen you stop No Yes breathing during sleep? P: PRESSURE Do you have/treated for high No Yes blood pressure? Q11 Nurses to Complete in clinic Score from STOP Less than 3 or more Weight 3 kg Height m BP mmHg bpm Pulse B: BMI <35 kg/m2 >35 kg/m2 A: AGE over 50 years <50 years >50 years N: NECK neck circumference No Yes (15.5” female / 17” male) G: GENDER Female Male Score from STOPBANG Less than 3 or 4 5 or more 3
Go to Q6a Q5b Is your sugar well controlled? Yes No Q6a Have you had or are you treated for fits or blackouts? No Go to Q7a Yes Q6b Have you had tests and are the results known? Yes No Q6c Are the symptoms well controlled? Yes No Q7a Have you had or are you treated for: Excessive bleeding or bruising? Blood clots (DVT or PE)? Do you take blood thinning medicine (eg Aspirin, warfarin, clopidogrel etc)? No No No Yes Yes Yes Q7b Have you had: A stroke /TIA (mini Stroke) in the last 3 months? A recent DVT or PE? Cardiac stents in the last year? No No No Go to Q8a Yes Yes Yes Q8a Do you have a pacemaker or other implantable device? No Go to Q9 Yes Q8b Has the device been checked in the last year? Yes No Q9a Do you have any allergies? (Medicines, foods, latex etc) No Go to Q10 Yes Q9b If yes, do you suffer Nausea or vomiting A rash or swelling Q10a Have you ever been diagnosed with Obstructive Sleep Apnoea Syndrome (OSAS)? No Go to Q10b Yes & I use treatment (eg CPAP) Yes but I do not use treatment Q10b S: SNORING T: O: OBSERVED P: PRESSURE Do you snore loudly enough to be heard through closed doors? Do you feel tired in the daytime every day? Has anyone seen you stop breathing during sleep? Do you have/treated for high blood pressure? No No No No Yes Yes Yes Yes Q11 Nurses to Complete in clinic Score from STOP Weight Height BP Pulse Less than 3 kg m mmHg bpm 3 or more B: BMI A: AGE N: NECK G: GENDER over 50 years neck circumference (15.5” female / 17” male) <35 kg/m2 <50 years No Female >35 kg/m2 >50 years Yes Male Score from STOPBANG Less than 3 3 or 4 5 or more
outpatients-pre-attendance-questionnaire-sfhft.docx