Referring Physician

Referring Physician

We welcome your interest in evaluating your patients for Sleep Disorders. Please have your patient complete the following Sleep Assessment Form. We appreciate your trust and referrals.

Sleep Assessment Form

Patient’s name:

Date of Birth:

Gender:

Male  Female

Primary Insurance:

Patient phone No:


PRIOR SLEEP TESTING & TREATMENT

Have you ever been diagnosed with a Sleep Disorder?

Yes No

If yes, when and what diagnosis did you receive?

Has your Sleep Disorder Treatment resolved your symptoms?

Yes No

Do you use a CPAP when sleeping?

Yes No

Do you use prescription or over the counter Sleep Aids?

Yes No

PRIOR SLEEP TESTING & TREATMENT

Do you Snore?

Yes No

Are you excessively tired during waking hours?

Have you been told that you stop breathing during sleep?

Yes No

Do you have a history of Hypertension? Diabetes? Stroke?

Yes No

Are you overweight? Neck size > 17inch (male) or > 16inch (female)?

Yes No
“YES” to two (or more) of these questions is a positive screen for Sleep Apnea.

Referral for Sleep Specific Assessment

                         
Referring Physician               Referring Physician NPI #             Physician phone number

                        
Physician Fax Number          Physician Office Address             Referral Date

Abha Mishra, MD, Medical Director Toll Free Sleep Phone (866) 520-5646; Sleep Fax (877) 904-0653

    

Sleep Disorders & Test

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