Patient Name: _____________________________________
|
Date of Birth: _____________________________________
|
Telephone: _____________________________________
|
Cell Number: ___________________________________
|
Prescribing Physician Name:
_____________________________________________________________________________
|
Telephone: _____________________________________
|
Fax Number: ___________________________________
|
Services Requested:
|
__ One time visit with Diplomate of American Board of Sleep
Medicine to assist in Evaluation,
History and Physical, determination of appropriate sleep
study required, and detailed
recommendations. (History/Physical section not needed. Fax
this form to the Sleep Center)
|
__ Sleep Study Only. Please fill out and fax this H/P form to
Sleep Center for review by D'ABSM.
|
History and Physical:
|
SLEEP PROBLEMS
|
__ Witnessed Apneas
|
__ Tiredness/Fatigue
|
__ Excessive Daytime Sleepiness
|
__ Insomnia
|
__ Snoring
|
__ Cataplexy
|
__ Frequent Awakenings
|
__ Sleep Walking
|
__ Morning Headaches
|
|
__ Other: ________________________________________________
|
MEDICAL CONDITIONS
|
__ HTN
|
__ GERD
|
__ CHF
|
__ Diabetes
|
__ Cardiac Arrhythmias
|
__ COPD/Asthma
|
__ Stroke/Seizures
|
|
__ Other: ________________________________________________
|
PHYSICAL EXAM
|
Heart __ Normal
|
__ Abnormal:
_______________________________________
|
Lungs __ Normal
|
__
Abnormal: ______________________________________
|
Abdomen __ Normal
|
__ Abnormal: ____________________________________
|
CNS __ Normal
|
__ Abnormal:
________________________________________
|
HEENT __ Normal
|
__
Abnormal: _______________________________________
|
PRESUMPTIVE DIAGNOSIS
|
__ Sleep Apnea
|
__ Sleepwalking
|
__ Narcolepsy
|
__ Hypersomnia
|
__ PLMD/Restless Legs
|
__ Insomnia
|
__ Nocturnal Seizures
|
__
|
__ Other: ________________________________________________
|
TYPE OF STUDY
|
__ Basic Polysomnogram CPT 95810
|
__ MSLT CPT 95805****
|
|
__ CPAP/BIPAP Titration CPT 95811
|
__ MWT CPT 95805*****
|
|
__ Split Night CPT 95811
|
|
|
