gulliksonsmiles.com - Sleep Breathing Disorder Form

SITUATION

	0	1	2	3
Sitting and reading
Watching Television
Sitting inactive in a public place (i.e. theater)
As a car passenger for an hour without a break
Lying down to rest in the afternoon
Sitting and talking to someone
Sitting quietly after lunch without alcohol
In a car, while stopping for a few minutes in traffic

TOTAL SCORE
A score of 6 or greater indicate the possibility of sleep disordered breathing.
AFTER THERAPY

SITUATION

	0	1	2	3
Sitting and reading
Watching Television
Sitting inactive in a public place (i.e. theater)
As a car passenger for an hour without a break
Lying down to rest in the afternoon
Sitting and talking to someone
Sitting quietly after lunch without alcohol
In a car, while stopping for a few minutes in traffic

TOTAL SCORE
A score of 6 or greater indicate the possibility of sleep disordered breathing.
THORNTON SNORING SCALE
Snoring has a significant effect on the quality of life for many people. Snoring can affect the person snoring and those around him/her, both physically and emotionally. Use the following scale to choose the most appropriate number for each situation. (Go to question #4 if you have no bed partner.)

0: Never
1: Infrequently (1 night per week)
2: Frequently (2-3 nights per week)
3: Most of the time (4 or more nights per week)
Previous therapy

NoneCpapSurgeryOther
BEFORE THERAPY

SITUATION

	0	1	2	3
My snoring affects my relationship with my partner
My snoring causes my partner to be irritable or tired
My snoring required us to sleep in separate rooms
My snoring is loud
My snoring affects people when I am sleeping away from home (i.e. hotel, camping, etc.)

TOTAL SCORE
A score of 5 or greater indicates your snoring may be significantly affecting your quality of life.
AFTER THERAPY

SITUATION

	0	1	2	3
My snoring affects my relationship with my partner
My snoring causes my partner to be irritable or tired
My snoring required us to sleep in separate rooms
My snoring is loud
My snoring affects people when I am sleeping away from home (i.e. hotel, camping, etc.)

TOTAL SCORE
A score of 5 or greater indicates your snoring may be significantly affecting your quality of life.
Should be Empty:

SLEEP BREATHING DISORDER SCREEN