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?
       Always snore?
       Snore loudly?
       Have "heavy" or loud breathing?
       Have trouble breathing, or struggle to breathe?



  2.  Have you ever seen your partner stop breathing during the night?
     



  3.  Does your partner:
       Tend to breathe through the mouth during the day?
       Have a dry mouth on waking up in the morning?



  4.  Does your partner:
       Wake up feeling unrefreshed in the morning?
       Have a problem with sleepiness during the day?



  5.  Has a friend, coworker or supervisor commented that your partner appears sleepy during the day?
      



  6.  Is it hard to wake your partner up in the morning?
      



  7.  Does your partner wake up with headaches in the morning?
      



  8.  Is your partner overweight?