SLEEP QUESTIONNAIRE II.
[To be completed by a family member or friend who
has observed the patient's sleep and alertness.] 

Name _____________________________________________________________________________

Name of patient ____________________________________________________________________

Your relationship to the patient _______________________________________________________

Patient's telephone: (_____) - ______- _________ Your telephone: (_____) - ______- _________

Your address _______________________________________________________________________

Your E-mail address _________________________________________________________________

Patient's doctor ____________________________________________________________________

Patient's doctor's address ____________________________________________________________

TO THE OBSERVER: WE APPRECIATE YOUR INPUT! YOUR RESPONSES TO THE FOLLOWING
MAY HELP PROVIDE EXPLANATIONS FOR THE SLEEP PROBLEMS OF THOSE CLOSE TO YOU.
 

A. WHAT OPPORTUNITIES HAVE YOU HAD TO OBSERVE THE PERSON'S SLEEP?

___ Frequent: share bed or bedroom and sleep lightly.

___ Have had little or no opportunity to observe the person during sleep.

B. IF YOU NO LONGER CAN SLEEP IN THE SAME BED OR BEDROOM AS THE PERSON, WHY NOT?

C. IF THE PERSON SNORES, WHICH OF THE FOLLOWING APPLY?

___ frequent snoring	___ snoring is irregular with gasps
___ loud snoring	___ struggling to breathe
___ long pauses in breathing occur	___ turns blue/ dusky
___ have prodded person to stimulate breathing	___ the breathing problem is frightening!

D. WHAT OTHER EVENTS DURING SLEEP HAVE YOU NOTICED?

___ sitting or standing up in sleep ___ screaming out	___ repetitive body jerks
___ acting out of dreams ___ heavy sweating	___ biting tongue/inside of mouth
___ sleepwalking ___ generalized shaking	___ choking/gagging/vomiting
___ running or frantic/violent behavior ___ eyes rolling up	___ bedwetting

E. WHICH OF THE FOLLOWING EVENTS HAVE YOU NOTED DURING WAKEFULNESS?

___ seems too sleepy	___ personality change/ irritability	___ muscular weakness or collapse with emotions
___ falls asleep at inappropriate times	___ confusion or worsening memory	___ seizures or convulsions
___ falls asleep when driving/ talking	___ episodes of staring/"going blank"	___ episodes of panic or intense anxiety

The results of this free review will then be shared with the patient and/or the patient's doctor.

Thank you for helping us help the patient!