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The Snoring and Apnea Center of California Culver Medical Plaza3831 Hughes Avenue, Suite 504 Culver City, CA 90232 Telephone: (310) 204-2798 E-mail: appointments@drkayem.com
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Please answer the following questions as accurately and thoroughly as possible:
1.
What is your usual bedtime:
2.
What is your weekday morning wake up time:
3.
How many times do you wake up during the night:
What wakes you up:
4.
Do you feel refreshed or tired in the morning?
5.
Do you have a headache in the morning?
6.
How often do you snore?
7.
How would you describe your snoring / breathing as described
by others (such as bed partners, roommates, etc…):
8.
What is your usual sleep position (on your back, stomach,
sides?):
9.
Does changing your sleep position make the snoring *better
or *worse?
Which positions?
10.
Do you feel sleepy or fall asleep easily during the day?: *No
*Yes
11.
Do you feel sleepy when driving? *No
*Yes
12.
Do you have difficulty with memory, concentration or overall
daily functioning? If so, please explain:
13.
Have you experienced problems with bed partners / roommates
complaining about your snoring / sleep apnea?
14. Do you have trouble breathing through your nose:
15.
Do you have *nasal allergies, *nasal
polyps, or *sinusitis?
16.
Have you had your tonsils and/or adenoids removed?
17.
Please list any and all nose, throat or mouth surgeries you
have had:
18.
Have you ever been diagnosed with sleep apnea? *No
*Yes:
19.
Please list all your medications (including any over the
counter medicines, sleeping pills, nose sprays, etc…):
20.
Do you have any of the following?
Heart Problems: *No
*Yes:
Lung Problems: *No
*Yes:
High Blood Pressure: *No
*Yes:
Thyroid Problems: *No
*Yes:
Endocrine Problems: *No
*Yes:
Heartburn / Reflux: *No
*Yes:
Other: *No
*Yes:
21. Do you smoke? *No *Yes: How much
22. Do you drink alcohol? *No *Yes: How much, how often:
23. Do you consider yourself overweight? *No *Yes
24. What is your height? What is your weight?
25. List all languages fluently spoken:
26. What is your profession / occupation?
27. Do you have any other comment that you have not mentioned?
Your name:
Date: Signature: