Mid-west center for sleep disorders
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Form
Patient Name:
Sex:
Male
Female
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REASON FOR STUDY: PATIENT IS EXHIBITING THESE SYMPTOMS BELOW
Daytime Sleepiness/Fatigue
Loud/Irregular Snoring *
Observed Apneas (stops breathing while sleeping)
Nocturnal Arousals (wake up during sleep)
Nocturnal Choking* (sensation of choking/actually choking)
Restless Sleep
Leg Jerks/Restless Legs
Poss. Nocturnal 02 desat
Morning Headaches
REM Behavior Disorder (violent movements during sleep)
Post-Op
High Blood Pressure
Cataplexy (muscle weakness triggered by type of emotion i.e., laughing/anger)
Other
Sleep Study: Initial Sleep Study first followed by CPAP/Bi-Level Ventilation/02 Titration per lab protocol, and then clinical follow up.
Comprehensive Clinic Evaluation: includes initial consultation with sleep specialist first, then sleep study(s) if needed and follow up with sleep specialist.
Sleep Study with MSLT (Multiple Sleep Latency Test):
Reason
Evaluate for Home Sleep Study
Other
REFERRING PHYSICIAN INFORMATION
Physician Name:
Office Contact:
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