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Dr. Ken Magid, DDS, FICD
Dr. Sabrina Magid-Katz, DMD
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Sleep Study Questionnaire
Name
*
Email
*
Phone
*
Age
*
Height
*
Weight
*
Gender
*
Have you ever had an evaluation at a sleep center?
*
yes
no
Sleep Center name
Location
Sleep Study Details
CPAP (Continuous Positive Airway Pressure) Intolerance
If you have attempted treatment with a CPAP device, but could not tolerate it, please fill in this section.
Mask Leaks
I was unable to get the mask to fit properly
discomfort caused by the straps and or headgear
disturbed or interrupted sleep caused by the presence of the device
Noise from the device disturbing my sleep and/or bed partner's sleep
CPAP restricted movements during sleep
CPAP does not seem to be effective
Pressure on the upper lip causing tooth replacement problems
Latex allergy
Claustrophobic associations
An unconscious need to remove the CPAP apparatus at night
other
Other Therapy Attempts
What other therapies have you had for breathing disorders? (Weight-loss attempts, smoking cessation for at least one month, surgeries, etc.)
Do you Snore?
Select One
3-4 times a week
1-2 times a week
1-2 times a month
never or almost never
How Loud do you snore?
Select One
Slightly Louder than breathing
as loud as talking
louder than talking
very loud. Can be heard in adjacent rooms
Does your snoring bother other people?
Select One
yes
no
Has anyone noticed that you quit breathing during your sleep?
Select One
yes
no
How often do you feel tired or fatigued after you sleep?
Select One
3-4 times a week
1-2 times a week
1-2 times a month
never or almost never
Durring your waketime, do you feel tired or not up to par?
Select One
3-4 times a week
1-2 times a week
1-2 times a month
never or almost never
Have you ever nodded off or fallen asleep while driving a vehicle?
Select One
yes
no
If yes, how often does it occur?
Select One
3-4 times a week
1-2 times a week
1-2 times a month
never or almost never
Do you have high blood pressure?
Select One
yes
no
i don't know
The Epworth Sleepiness Scale
How likely are you to doze off or fall asleep in the following situations?
Sitting and reading?
Select One
No Chance of Dozing
Slight Chance of Dozing
Moderate Chance of Dozing
High Chance of Dozing
Sitting in public (e.g.:theatre, meeting or church)
Select One
No Chance of Dozing
Slight Chance of Dozing
Moderate Chance of Dozing
High Chance of Dozing
As a passenger in a car for an hour without a break
Select One
No Chance of Dozing
Slight Chance of Dozing
Moderate Chance of Dozing
High Chance of Dozing
Watching tv
Select One
No Chance of Dozing
Slight Chance of Dozing
Moderate Chance of Dozing
High Chance of Dozing
Lying down to rest in the afternoon when circumstance permit
Select One
No Chance of Dozing
Slight Chance of Dozing
Moderate Chance of Dozing
High Chance of Dozing
Sitting and talking to someone
Select One
No Chance of Dozing
Slight Chance of Dozing
Moderate Chance of Dozing
High Chance of Dozing
Untitled
Select One
No Chance of Dozing
Slight Chance of Dozing
Moderate Chance of Dozing
High Chance of Dozing
Request a Consult
What Kind of Appointment?
*
Dental Reconstruction Consult
Smile Esthetics Consult
Dental Implants Consult
Snoring/Sleep Apnea Consult
Special Requests:
Full Name:
*
Email:
*
Phone:
*
Contact Us
Advanced Dentistry of Westchester
Kenneth S. Magid, DDS, FICD
Sabrina Magid-Katz, DMD
163 Halstead Ave. • Harrison, NY 10528
(914) 835-0542
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