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.
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)

• 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.