Second Party Questionnaire Obstructive Sleep Apnea
Patient First Name:
Patient Last Name:
Name of second party completing form:
Please Answer the following questions as they pertain to your bed partner in the past month:
1. While sleeping does your partner:
Snore more than half the time?
Yes
No
Don't Know
Always snore?
Yes
No
Don't Know
Snore loudly?
Yes
No
Don't Know
Have "heavy" or loud breathing?
Yes
No
Don't Know
Have trouble breathing, or struggle to breathe?
Yes
No
Don't Know
2. Have you ever seen your partner stop breathing during the night?
Yes
No
Don't Know
3. Does your partner:
Tend to breathe through the mouth during the day?
Yes
No
Don't Know
Have a dry mouth on waking up in the morning?
Yes
No
Don't Know
4. Does your partner:
Wake up feeling unrefreshed in the morning?
Yes
No
Don't Know
Have a problem with sleepiness during the day?
Yes
No
Don't Know
5. Has a friend, coworker or supervisor commented that your partner appears sleepy during the day?
Yes
No
Don't Know
6. Is it hard to wake your partner up in the morning?
Yes
No
Don't Know
7. Does your partner wake up with headaches in the morning?
Yes
No
Don't Know
8. Is your partner overweight?
Yes
No
Don't Know