Sleep Disorder Referral Questionnaire
Please complete the following questions to expedite your referral. Our staff will contact your patient to schedule the appointment. Please include your telephone number and email address to enable us to contact you if we need additional information and to ensure confirmation of your referral.
Your Name:
Your Telephone (& Extension):
Your Email Address(to confirm):
Referring Doctor:
Patient Name:
Patient Contact Information
(Telephone, Cell, Email):
Patient Date of Birth:
Suspected Diagnosis:
Click to Select Suspected Diagnosis
Unsure - Sleep Consult Requested
Obstructive Sleep Apnea/Snoring
--- Consult suggested for below diganosis ---
Sleepiness (other than Sleep Apnea)
Insomnia
Parasomnia/Nocturnal Seizures
Limb Movements/Restless Legs
Type of Sleep Study:
Click to Select Type of Evaluation
Sleep Medicine Consult
Polysomnogram (PSG - Overnight Sleep Study)
Polysomnogram - Split Night (if possible)
CPAP/BiPAP Titration
Multiple Sleep Latency Test (MSLT) with PSG
Maintenance of Wakefullness Test (MWT)
Location (click to select):
Click to Select
Dover Office
Milford Office
Please complete the following if sleep study requested (not required for sleep consultation).
Symptoms
Loud Snoring:
Drowsy when driving:
Stops breathing during sleep:
Daytime fatigue or napping:
Awakens with difficulty breathing:
Restless or jerky legs:
Medical Data
Hypertension:
Cardiac disease:
Stroke or TIA:
Diabetes:
Obesity:
Asthma or COPD:
Blood Pressure:
Height:
Weight:
Physical Exam:
(pertinent findings):
Medications:
(please list):
Consultation
Sleep Medicine Consultation:
If study is normal or abnormal.
Only if sleep study abnormal.
Please email, send or fax pertinent medical records presently with this sleep disorder request.
Records can be emailed directly to:
Pepper Fausnaught
or faxed to her attention at 302-346-2533.