The Bed Partners Questionnaire


In the last blog we looked at the Epworth Questionnaire, as it is a good way for an individual to determine whether they suffer from excessive daytime sleepiness…

The degree or severity of daytime sleepiness is a good measure of what a person’s sleep quality is like.

However, it is a good idea to look at what your bed partner has to say, as they may be witnessing certain behavior first hand I.e., snoring, gasping for breath, body movement.

The questionnaire below is a subjective look at how severe your bed partner feels that your snoring is.

Snoring is a strong indicator of Obstructive Sleep Apnea, so it’s good to get the bed-partner’s feed-back if possible.

Please answer the following questions as follows:
1—never, 2—rarely, 3—sometimes, 4—often, 5—always
1. Does your husband/wife snore loudly?
2. Does your husband/wife snore in all positions?
3. How often were you kept awake by snoring?
4. How often were you forced to sleep in another room?

The more information the bed partner can give concerning the affected individual, the better. But it goes beyond snoring; anything witnessed that’s of a physical nature, I.e., leg movements or anything heard (teeth grinding, gasping for air or choking, sleep talking) The bed partner’s input is an important part of the patient’s need for more follow up and a definitive diagnosis .

To help us obtain a proper diagnosis and an appropriate treatment plan, have your bed partner, if applicable and available, fill out this questionnaire regarding your sleep habits. This information is vitally important for your dentist or sleep doctor to best evaluate your condition.


1. YES NO Do you witness the patient snoring?_____________________
2. YES NO Do you witness the patient choking or gasping for breath during
3. YES NO Does the patient pause or stop breathing during sleep? _____________
4. YES NO Does the patient fall asleep easily, if given the opportunity, during the day (normal wakeful hours)?_______________
5. YES NO Do you witness the patient clenching and/or grinding his/her teeth during sleep?____________
6. YES NO Does the patient appear refreshed upon waking? ____________
7. YES NO Do the patient’s sleep habits disturb your sleep? _____________
8. YES NO Does the patient sit up in bed, not awake? _________________
9. Please check those sleep habits of the patient that are disturbing to you:
 Snores
 Restless
 Wakes up often
 Loud gasping for breath while sleeping
 Stops breathing
 Grinds teeth
 Becoming very rigid or shaking
 Biting tongue
 Kicking during sleep
 Head rocking or banging
 Bed-wetting
 Sleep walking
 Sleep talking
 Other_________________________


The two questionnaires above along with the Epworth are really important in order to help evaluate a patient’s condition.

Combine this information with any of the symptoms listed in the blog “ Sleep Apnea – Symptoms Revisited “ posted on December 1,st 2013 and what you get is a good indicator of whether an individual may be suffering from some type of sleep deprivation…most likely Obstructive Sleep Apnea.

Once we have all of this ‘preliminary information,’ we can move to the next step, which is a sleep study conducted by a Sleep Specialist. Once we have a diagnosis, we can put forth an appropriate treatment plan which will help you to live a healthier and productive life.

Yours in good health,

Dr. F. Keshavarz Dentistry

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