Print out the following form and take it with you when you see your doctor. Your doctor will fill out this form and fax it to us when he/she refers you to our center for a sleep study

Idaho Diagnostic Sleep Center

526-C Shoup Avenue West - Twin Falls, ID 83301

Phone: (208) 736-7646 - Toll-Free: (877) 260-7646 - Fax: (208) 736-1569

*Accredited by the American Academy of Sleep Medicine

Attending Physician Referral Prescription Form for Diagnostic Sleep Procedures

Patient's Name: ____________________________________________________________

Address: ___________________________________________________________________

Date of Birth: ____ / ____ / ____ Weight: _____________ Height: ____________

INFORMATION BELOW TO BE ENTERED BY PHYSICIAN OR PHYSICIAN EMPLOYEE

1. Recommended Procedures:

Sleep Study-1st Night
CPAP Titration-2nd Night if Indicated

Sleep Study – 1st Night

CPAP Titration

Split Noc Study

Consultaion Prior to Study

Overnight Oximetry

Multiple Sleep Latency Test (For Suspected Narcolepsy Preceded by Overnight Sleep Study)

Insomnia Counseling (Appt. with Sleep Specialist)

2. Primary Diagnosis: ________________________________________________________

Suspected Diagnosis (Please Circle):

Sleep Apnea    Insomnia    Periodic Limb Movements    Narcolepsy    Other: ________________

Risk Factors - CHECK ALL THAT APPLY:

Observed Apnea

Daytime Somnolence

Cataplexy

Hypertension

Seizure

Lung Disease

Heart Disease/Arrhythmia

Night Terrors

Other Pertinent Information: __________________________________________________

____________________________________________________________________________

Is Patient Currently on Oxygen? YES____NO____

If so: _____ LPM      Continuous_____ PRN _____ NOC_____

_________________________________________________MD     ______ / ______ / ______

Attending Physician's Signature     Date

Area below dotted line is for office use only

Date of scheduled test: _____________     Patient information received:

____________ H&P ____________ ABG’s

____________ Lab ____________ Other (specify)

____________ Patient Sleep Questionnaire

_________________________________________________MD		______ / ______ / ______
Attending Physician's Signature		Date

Date of scheduled test: _____________	Patient information received:
	____________ H&P	____________ ABG’s
	____________ Lab	____________ Other (specify)
	____________ Patient Sleep Questionnaire