Croton-on-Hudson Sleep Apnea Questionnaire

Do you have sleep apnea? Take our patient survey and find out!

At Smiles on Hudson, we understand that quality sleep is essential for your overall health and well-being, which is why we offer comprehensive testing for sleep apnea to help diagnose and treat this common sleep disorder.

This patient survey is designed to help you determine if you may be suffering from sleep apnea and if you are a good candidate for further testing. Take it today and start your journey to better sleep!

Sleep Apnea Questionnaire

"*" indicates required fields

Have you been diagnosed or treated for any of the following conditions?

High blood pressure*
Heart disease*
Sleep apnea*
Lung disease*
Sleeping medication*
Nasal oxygen use*
Restless leg syndrome*
Morning headaches*
Pain medication (e.g. vicodin, oxycontin)*

Epworth Sleepiness Scale

How likely are you to doze off or fall asleep in the following situations, in contrast to just feeling tired? This refers to your usual way of life in recent times. Even if you have not done some of these things recently, try to work out how they would have affected you. Use the following scale to mark the most appropriate box for each situation.
(M.W. Johns, Sleep 1991)

0 = would never doze
1 = slight chance of dozing
2 = moderate chance of dozing
3 = high chance of dozing

Sitting and reading*
Watching TV*
Sitting, inactive, in a public place (theater, meeting, etc)*
As a passenger in a car for an hour without a break*
Lying down to rest in the afternoon when circumstances permit*
Sitting and talking to someone*
Sitting quietly after lunch without alcohol*
In a car, while stopped for a few minutes in traffic*


On average in the past month, how often have you snored or been told that you snored?*
Do you wake up choking or gasping?*
Have you been told that you stop breathing in your sleep or wake up choking or gasping?*
Do you have problems keeping your legs still at night or need to move them to feel comfortable?*

From the time you walk in, you feel comfortable and welcomed. Dr. Gold explains in detail any procedure he’s going to do. I can’t say enough good things.

— Diane L.

Get Started Today

We look forward to welcoming you to our office and providing quality care.

Our Croton-on-Hudson dental office

2018 Albany Post Road
Croton-On-Hudson, NY 10520


Monday - Friday
7:30am - 5:30pm
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