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Sleep Behavior Scale

The following questions are designed to define your sleep behavior.  Choose the most appropriate number for each situation.  To send this to the doctor, fill in the blanks and click on "Send to Doctor"

A score of 8 or more indicates your sleep behavior is likely to cause a problem for you or others!!

Name:

Phone:

E-mail:

During a typical night's sleep, have you noticed or been told that you:

Snore in a manner that affects your bed partner Pick One 0=Never 1=Once a week 2=Two-three nights/week 3=Four or more times/week

Snore in a manner that affects others when sleeping Pick One 0=Never 1=Once a week 2=Two-three nights/week 3=Four or more times/week

Stop breathing or "hold your breath" Pick One 0=Never 1=Once a week 2=Two-three nights/week 3=Four or more times/week

Toss and turn frequently Pick One 0=Never 1=Once a week 2=Two-three nights/week 3=Four or more times/week

Cough and/or struggle for breath Pick One 0=Never 1=Once a week 2=Two-three nights/week 3=Four or more times/week

Sweat excessively Pick One 0=Never 1=Once a week 2=Two-three nights/week 3=Four or more times/week

After a typical night's sleep, have you noticed the following:

Headache Pick One 0=Never 1=Once a week 2=Two-three nights/week 3=Four or more times/week

Feel tired and feel a lack of energy Pick One 0=Never 1=Once a week 2=Two-three nights/week 3=Four or more times/week

Lose concentration and/or more forgetful Pick One 0=Never 1=Once a week 2=Two-three nights/week 3=Four or more times/week

Sleepiness during the day Pick One 0=Never 1=Once a week 2=Two-three nights/week 3=Four or more times/week

Feel depressed or "down" Pick One 0=Never 1=Once a week 2=Two-three nights/week 3=Four or more times/week

Dry and/or sore throat Pick One 0=Never 1=Once a week 2=Two-three nights/week 3=Four or more times/week

Total Score 

  

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