Bed Partner Questionnaire

Name Of Patient

Relationship to Patient

How often have you observed this person's sleep
Once or twice
Every night

Has this person fallen asleep during normal daytime activities or in dangerous situations? Explain

What behaviors have you observed in this person while he/she was asleep?
Light snoring
Loud snoring
Occasional loud snorts
Pauses in breathing
Limb movement every 10-20 secs.
Awakening with pain
Leg or arm twitching
Leg kicking
Shaking or rocking
Becoming very rigid
Teeth grinding
Sitting up in bed
Head rocking/banging

Please describe the checked behaviors in more detail. Include a description of the behaviors , when during the night, how often every night and how many nights a week do these behaviors occur.

Sleep Apnea Questionnaire

Epworth snoring Questionnaire