Office of Keerthi Senthil DDS, MS 72027 Desert Drive, Rancho Mirage,CA 92270 (760) 340- 5107 Today’s Date: __________________ Sleep Health Questionnaire Patient Name: Last __________________ Middle __________________ First __________________ Home Phone (include area code) __________________ Work Phone (include area code) __________________ Mobile Phone (include area code) __________________ Address __________________ City __________________ State __________________ Zip Code __________________ Email __________________ Mailing Address __________________ Date of Birth __________________ Sex M __ F __ Height __________________ Weight __________________ Occupation __________________ Employer Name, Address __________________ Marital Status: Single __ Married __ Divorced __ Separated __ Social Security Number Emergency Contact Relationship to Patient __________________ __________________ __________________ Their Home Phone Their Cell Phone __________________ __________________ Have you ever fallen sleep or nodded off while driving? __ Yes __ No 6 Have you ever woken up suddenly with shortness of breath, gasping or with your heart racing? __ Yes __ No 6 Do you feel excessively tired during the day? __ Yes __ No 4 Do you snore or have been told that you snore? __ Yes __ No 4 Have you had weight gain and found it difficult to lose? __ Yes __ No 2 Have you taken medication for, or been diagnosed with high blood pressure? __ Ye __ No 2 Do you kick or jerk your legs while sleeping? __ Yes __ No 3 Do you feel burning, tingling or crawling sensation in your legs when you wake up? __ Yes __ No 3 Do you wake up with headaches during the night or in the morning? __ Yes __ No 3 Do you have trouble falling asleep? __ Yes __ No 4 Do you have trouble staying asleep once you fall asleep? __ Yes __ No 4 Have you been told you stop breathing in your sleep? __ Yes __ No 8 TOTAL SCORE: __________ Risk Level Score Low 0-7 Medium 8-11 High 12-15 Severe 16+ Signs and Symptoms. Please indicate all that apply __ Family History of Snoring or Sleep Apnea __ Stroke/ Heart Disease __ Un-refreshed Sleep __ Depression __ Grind Teeth __ Acid Reflux __ Hypertension __ Snoring __ Diabetes Sleep History. Please indicate all that apply Have you ever been diagnosed with a Sleep Disorder? Yes __ No __ Are you currently using a CPAP machine? Yes __ No __ Do you use your CPAP less than 5 times a week? Yes __ No __ Would you prefer an oral device or appliance? Yes __ No __ Patient’s Signature __________________ Date __________________