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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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