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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:
Height:
Weight:
Occupation:
Employer Name, Address:
Marital Status:

Social Security Number:
Emergency Contact:
Relationship to Patient:
Their Home Phone:
Their Cell Phone:

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
Acid Reflux
Snoring
Grind Teeth
Hypertension
Diabetes

Sleep History. Please indicate all that apply


Patient's Signature:

Use your mouse cursor or the tip of your finger to sign above

Date: