Diagnosis & Treatment

Sleep Observer Questionnaire

The following questions relate to the behavior that you have observed in the patient while he/she is asleep. Use the following scale to choose the most appropriate number for each situation.

0=Never
1=Infrequently (1 night per week)
2=Frequently (2-3 nights per week)
3=Most of the time (4 or more nights per week)

SymptomScore
Loud, irritating snoring____
Choking or gasping for air____
Pauses in breathing____
Twitching / kicking of arms or legs____
Snoring requiring separate bedrooms____
Falling asleep inappropriately (example: while driving or at meetings)____
Total____

 

A score of 5 or greater indicates symptoms which are affecting the health, safety, or quality of life of the observed person.

 


Self Sleep Evaluation

Sleep Apnea

  1. I have been told I snore.
  2. I have been told I stop breathing when I sleep, although I may not remember this when I wake up.
  3. I feel sleepy during the day even though I slept through the night.
  4. I have been told that I am a restless sleeper-that I toss and turn a lot at night.
  5. I sweat excessively during the night.
  6. I frequently awaken with headaches.
  7. I have high blood pressure.
  8. I am overweight and/or have a recent significant weight gain.
  9. I seem to be loosing my sex drive.

 


The Epworth Sleepiness Scale

How likely are you to doze off or fall asleep in the following situations?

Choose the most appropriate number for each situation:
0 = would never doze
1 = slight chance of dozing
2 = moderate chance of dozing
3 = high chance of dozing

ActivityScore
Sitting and Reading____
Watching TV____
Sitting, inactive in a public place (theater, meeting, etc.)____
As a passenger in a car for an hour without a break____
Lying down to rest in the afternoon when circumstances permit____
Sitting and talking to someone____
Sitting quietly after lunch without alcohol____
In a car, while stopped for a few minutes in traffic____
Total____

A score of 9 or above indicates you may be having a problem with daytime sleepiness but below 9 does not necessarily mean that you don’t have a problem. See your healthcare professional for advice if you snore, have been told that you awake gasping for breath or if you are sleepy during the day.