STOP-Bang Sleep Apnea Screening – CY Men’s Health Clinic

CY Men’s Health Clinic — STOP-Bang Sleep Apnea Screening

Sleep apnea screening for men’s health and TRT safety documentation. This screening tool estimates risk and does not diagnose obstructive sleep apnea. Diagnosis requires appropriate clinical evaluation and sleep testing when indicated.

1. Patient Information

Patient Name

Date of Birth

Age

Date

Phone

Preferred Language

Reason for Screening

2. Measurements / Context

Height

Weight

BMI

Neck Circumference

Blood Pressure

Currently on TRT?

Prior Sleep Study?

Known Sleep Apnea?

Uses CPAP/BiPAP?

Most Recent Hematocrit

Provider Name

3. STOP-Bang Questions

Important: Untreated significant obstructive sleep apnea can increase risk during TRT, especially if hematocrit rises, blood pressure is uncontrolled, or symptoms are severe.

4. Additional Sleep / Safety Questions

Wakes Up Choking/Gasping?

Morning Headaches?

Dry Mouth on Waking?

Falls Asleep Driving?

Work/Driving Safety Concern?

Alcohol or Sedatives at Night?

Additional Sleep Notes

5. Score Summary

Click “Calculate Risk” or “Generate Note” to calculate STOP-Bang risk.

STOP-Bang Score / 8

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Risk Category

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TRT Safety Flag

6. Provider Action / Plan

Sleep Study Needed?

TRT Decision Impact

Referral

Provider Plan / Comments

7. Patient Handwritten Signature

Patient may sign below using mouse, finger, or stylus.

Patient Signature Name Printed

Signature Date

Signature Captured?

Sign inside the box above.

8. Generated Chart Note

Use this as a draft. Review clinically before saving in the EHR.