The following questions relate to the behavior that you have observed in the patient, your bed partner, 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)

  1. __ Loud, obtrusive or irritating snoring
  2. __ Choking or gasping for air
  3. __ Pauses in breathing
  4. __ Twitching / kicking of arms or legs
  5. __ Snoring requiring separate bedrooms
  6. __ Falling asleep inappropriately (ex. While driving or in meetings)

Total Score: __

Understanding Your Score

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