2019-08-07_edited.png
KESPARA MEDICAL CENTER
22 Meridian Rd, Suite 10 Edison, NJ 08820
22 Meridian Rd, Suite 10 Edison, NJ 08820
Pullin Patel,MD
Internal Medicine
Ph:(732) 243-9808
Fax:(732) 791-5765
SLEEP QUESTIONNAIRE(PHQ-9)
Patient's Name : 
PHONE-
Home:
DOB:
Cell:
Date:
Address:
Do you snore loudly or have been told that you snore?
Do you feel tired, sleepy or fatigued during the day?
Has anyone observed you stop breathing during the sleep?
Do you have or are being treated for high blood pressure or Diabetes?
Do you fall asleep or nod off during the day?
Do you wake up gasping or choking?
Is your BMI more than 35?
Do you wake up with dry mouth?
If you answered YES to 3or more questions, You should get a home sleep test to evaluate the presence of Obstructive Sleep Apnea?