Dr. Greg Broyde BSc, DDS
Dr. Navdeep Dhaliwal BSc, DDS
526 Riverfront Ave SE
Calgary AB T2G 1E4
Ph: 403 263 9014

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.

Please estimate how many hours of sleep your bed partner gets

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

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.