Referral for Physicians - Sleep Wellness Centers of New York

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Ordering Practice:

Patient Name:

DOB:

Patient Address:

Patient Home Phone:

Work:

Cell:

Social Security #:

Referred By:

Primary Ins:		ID #:		Subscriber:		DOB:
Secondary Ins:		ID #:		Subscriber:		DOB:

Physical Exam:

Height:

Weight:

Blood Pressure:

Diagnosis:

	Sleep apnea (780.53/327.23)		Nocturnal Hypoventilation (327.26)
	Periodic leg movement disorder (780-52-4/327.51)		Other:
	Narcolepsy (347.00)

Patient Complaints:

Excessive daytime sleepiness

Early morning headache

Frequent Awakenings

Heavy snoring

Gastric Bypass Pending

Unusual Behavior

Witnessed apneic episodes

Insomnia

Other

Abnormal Leg Movements During/Prior to Sleep

Sleepiness While Driving

Obesity

Enlargement of soft palate/uvula

Crowded oropharynx

Tonsilar hypertrophy

Hypertension

Cardiovascular disease

Recent weight loss/gain

	Other significant findings
	Previous sleep study Findings

Orders

	PSG (95810)		CPAP/BILEVEL TITRATION (95811)		SPLIT (95811)
	MSLT (95805)		HOME Diagnostic / Titration (95806)

Mission Statement

To provide patients the means for consistent restorative sleep by employing the latest in diagnostic testing, treatment and counsel.

To conduct research and regularly contribute to the body of scientific and medical knowledge to gain a better understanding and treatment of sleep disorders.

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	Yes	No		Yes	No
Dozing at inappropriate times			Irritability
Night sweats			Obesity
Erectile Dysfunction [E.D.]			Poor memory
Excessive daytime sleepiness			Lack of concentration
Gasping for breath			Sensitivity to pain
Chronic fatigue			Snoring
High Blood Pressure			Pins and needles in your legs
Irregular heart beat

If you answered "Yes" to any of these questions, you may have sleep apnea. However, if you answered "Yes" to "excessive daytime sleepiness" or "snoring", this strongly suggests that you suffer from sleep apnea.