Bed Partner Questionnaire
Name of Patient: Date Completed:
Name of person filling out this form:
Relationship to Patient:
Once or twice often every night
1 pillow 2 pillows 3+ pillows
on their back on their side on their stomach
Yes No
Check any of the behaviors below that you have observed while this person was asleep:
light snoring
lod snoring
occasional lod snorts
pases in snoring
choking
pases in breathing
twitching or kicking of
arms and legs
other: _________________________________________________________________
Please describe the sleep behaviors marked above in more detail, including the time of night
they occur and the frequency with which they occur:
Has this person ever fallen asleep during normal daytime activities or in dangerous situations?
Yes
No
If yes, please explain:
have observed this persons sleep
his person sleeps in a bed with
his person sleeps in a bed
his person sleeps in a chair
getting ot of bed bt
not awake
apparently sleeping
even if they believe
otherwise
grinding teeth
sleepwalkingtalking
bed wetting
crying ot
sitting p in bed when not
awake
awakening with pain
headrocking or banging
becoming very rigid andor
shaking
NO BED PARTNER