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 Lab

526-C Shoup Avenue West - Twin Falls, ID 83301
Phone: (208) 736-7646 - Toll-Free: (877) 260-7646 - Fax: (208) 736-1569

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
(Consultation prior to study if required)
Sleep Study - 1st Night Only
CPAP Titration
Split Noc Study (if meets protocol)
Sleep Medicine Consultaion
Overnight Oximetry
Evaluation for Narcolepsy - Consultation with PSG/MSLT if Indicated

2. Primary Diagnosis: ________________________________________________________

Suspected Diagnosis (Please Circle):

Sleep Apnea    Insomnia    Periodic Limb Movements    Narcolepsy    Other: ________________

Risk Factors - CHECK ALL THAT APPLY:
Observed Apnea
Snoring
Daytime Somnolence
Nocturnal Hypoxia
Morning Headaches
Hypertension
Heart Disease/Arrhythmia
Seizure

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