224-24 Union Turnpike Suite 1-M Oakland Gardens, NY (718)468-3434
Dr. David Hershkowitz
(718)468-3434
The Office for Dental Arts
Home
Dr. David Hershkowitz
New Patient
New Patient Form
Sleep Health Questionnaire
Services
Extractions
Extraction Site Preservation
Dental Implants
Dental Bridges
Sleep Apnea
Professional Teeth Whitening
Snap on Smile
Crowns
Gum Health
Scaling Root Planing
Dental Hygiene and Periodontal Health
Soft Tissue Management
Contact Us
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)
---
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
Top
