Self Assessment Forms
A) Sleep Observer Questionairre
The following questions relate to the behavior that you have observed in the patient 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.
B) Self Sleep Evaluation
Sleep Apnea
- I have been told I snore.
- I have been told I stop breathing when I sleep, although I may not remember this when I wake up.
- I feel sleepy during the day even though I slept through the night.
- I have been told that I am a restless sleeper-that I toss and turn a lot at night.
- I sweat excessively during the night.
- I frequently awaken with headaches.
- I have high blood pressure.
- I am overweight and/or have a recent significant weight gain.
- I seem to be loosing my sex drive.
C) The Epworth Sleepiness Scale
How likely are you to doze off or fall asleep in the following situations?
Choose the most appropriate number for each situation:
0 = would never doze
1 = slight chance of dozing
2 = moderate chance of dozing
3 = high chance of dozing
Activity / Score
Sitting and Reading _____
Watching TV _____
Sitting, inactive in a public place (theater, meeting, etc.) _____
As a passenger in a car for an hour without a break _____
Lying down to rest in the afternoon when circumstances permit _____
Sitting and talking to someone _____
Sitting quietly after lunch without alcohol _____
In a car, while stopped for a few minutes in traffic _____
Total _____
A score of 9 or above indicates you may be having a problem with daytime sleepiness but below 9 does not necessarily mean that you don't have a problem. See your healthcare professional for advice if you snore, have been told that you awake gasping for breath or if you are sleepy during the day.
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