Observed Patient: ___________________________________
Sleep Observer Scale
The following questions relate to the behavior that you have observed in the patient is while he/she is asleep. Use the following scale to choose the most appropriate number for each situation.
1=Infrequently (1 night per week)
2=Frequently (2-3 nights per week)
3=Most of the time (4 or more nights per week)
- 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 score ______
A score of 5 or greater indicates symptoms which are affecting the health, safety, or quality of life of the observed person.