Please estimate how many hours of sleep your bed partner gets

Positions your bed partner sleeps in

Back

Side

Stomach

Does your bed partner snore

If they snore, please mark the positions they snore in

Back

Side

Stomach

How loud is his/her snoring?

Does your bed partner fall asleep without warning

Yes

No

Unknown

Does your bed partner fall asleep when driving

Yes

No

Unknown

Does your partner appear refreshed upon waking

Yes

No

If your bed partner awakens during the nigh! how long does it take them to get back to sleep

Do you know why he/she awakens

Yes

No

If yes, why

How much stress does your bed partner currently have?

Has your bed partner's mood, memory, concentration, or personality deteriorated or changed

Yes

No

If yes, please explain

Does your bed partner's sleep problems disrupt your sleep

Explain

Please estimate your bed partner's risk of falling asleep or dozing off in the following situations, using the following scale: 0=no chance, 1=slight chance, 2=moderate chance, 3=high chance.

Sitting and Reading

Watching TV

Sitting inactive, in public, theater, meetings, etc

Sitting and talking to someone

Lying down to rest in the afternoon

As a passenger in a car, for an hour, with no break

Sitting quietly after lunch, without alcohol

In a car, stopped in traffic, for a few minutes

Additional Comments regarding the patient's sleep habits not mentioned above:

	Hours each night	How long does it take to fall asleep (minutes)	Hours awake during the night
work days
days off

Does your bed partner do any of the following in his/her sleep? check all that apply
Gagging Choking Snorting Gasping	Teeth Grinding Kicking their feet Wakes Up Often Restless	Stops Breathing Becomes Very Rigid or Shaking Biting Tongue Head Rocking or Banging	Bed-Wetting Sleep Walking Sleep Talking Sits Up in Bed, not awake

BED PARTNER SURVEY

To help us with a proper diagnosis and appropriate treatment plan, have your bed partner, if applicable and available, fill out this questionnaire regarding YOUR sleep habits. This information is vitally important to best evaluate your current condition.