224-24 Union Turnpike Suite 1-M Oakland Gardens, NY (718)468-3434
Dr. David Hershkowitz
(718)468-3434
The Office for Dental Arts
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Dr. David Hershkowitz
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New Patient Form
Sleep Health Questionnaire
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Extractions
Extraction Site Preservation
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Sleep Apnea
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Consent to Treat Forms
Sleep Health Questionnaire
Date
Name (required)
Age (required)
Weight (required)
Phone
Email
Do you snore or have been told by someone that you snore? (required)
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YES - 2 points
NO
Has anyone ever noticed that you quit breathing during your sleep? (required)
---
YES - 3 points
NO
Do you ever awaken with a sensation of gasping or choking? (required)
---
YES - 3 points
NO
Do you often feel tired or fatigued immediately after getting up from sleep?(required)
---
YES - 1 point
NO
During your waking time, do you often feel tired, fatigued or not up to par?(required)
---
YES - 1 point
NO
Have you, in the past 6 months, nodded off or fallen asleep in any situation(s) where you did not intend to?(required)
---
YES - 1 point
NO
Do you have (or are being treated for) high blood pressure? (required)
---
YES - 1 point
NO
Total Points:
Please add up the points from the questionnaire that were answered 'Yes" If the point total is greater than 2, the patient is a good candidate for a diagnostic sleep study. 0-2 = Lower risk of having Obstructive Sleep Apnea 3-4 = Moderate risk of having Obstructive Sleep Apnea 5-12 = High risk of having Obstructive Sleep Apnea
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