Sleep Observer Scale – Chicago Smile Spa

Serving Chicago, Lakeview, Lincoln Park, and surrounding areas in Illinois

Name: ________________________________
Date: _____________
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.

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