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Patient Referral
Patient Information
Patient Name
*
Patient Phone Number
*
Format: (555) 555-5555
Birth Date
Year
Year
1921
1922
1923
1924
1925
1926
1927
1928
1929
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2010
2011
2012
2013
2014
2015
2016
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Day
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31
Last Patient Visit
Year
Year
2016
2017
2018
2019
2020
2021
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Day
1
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31
Sex
- None -
Male
Female
Height
Weight
lbs.
Address
Street Address
City
State
- None -
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Marshall Islands
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Marianas Islands
Ohio
Oklahoma
Oregon
Palau
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Postal Code
Insurance
Insurance Name
Company Phone Number
Additional
Is there anything else you would like to add about this patient? Please exclude sensitive information.
Sleep Disorder Information
Fill out the fields below if you're referring the patient for sleep medicine.
Presenting Symptoms
Snoring
Witnessed Apnea
Excessive Daytime Sleepiness
Unrefreshed Sleep
Morning Headache
Awakens choking/gasping
Awakens with dry mouth/sore throat
Insomnia
Near Miss/car accident
Restless legs/cramps/jerks
Decreased memory
Cataplexy/Hypnogogic hallucinations
Grinding teeth
Falls asleep inappropriately
Past Medical History
Obesity
HTN
CAD
Cardiac arrhythmia
COPD/asthma
Stroke/TIA
Diabetes
Seizure
Hypoventilation Syndrome
Pul. HTN
GERD
Upper Airway Resistance
Cognitive Impairment
Suspected Sleep Diagnosis
Obstructive sleep apnea (327.23)
Insomnia w/ sleep apnea (780.51)
Restless leg syndrome (333.94)
Narcolepsy (347) w/ cataplexy (347.01)
Hypersomnia with sleep apnea (780.53)
Sleep Study Prescribed
- None -
Consult sleep physician for evaluation and treatment
Current CPAP/BIPAP level needs re-evaluation
Current CPAP/BIPAP Level
If CPAP/BIPAP levels need re-evaluation, please provide their current setting.
Physician Information
Referring Physician Name
*
Email
*
Phone Number
*
Format: (555) 555-5555
Fax
How many cats?
*
How many dogs?