Schedule a Sleep Study

Patient Name:

Patient Date of Birth:

History / Symptoms:

Excessive daytime sleepiness

Loud snoring

Witnessed apnea (stop breathing during sleep)

Waking up with headaches

Daytime tiredness

Trouble falling asleep

Trouble maintaining sleep

Body paralysis triggered by emotion (cataplexy)

Vivid dreams soon after sleep onset

Sleep paralysis

Inadequate hours allotted for sleep in a day

Feel depressed or anxious

Restless legs preventing sleep

Leg jerks disrupting sleep

Other

Medical Problems:

Type of Test Requested:

Sleep study (polysomnogram) and CPAP if necessary

Sleep study (polysomnogram) only, if going for ENT surgery

Sleep study & MSLT (for diagnosis of narcolepsy)

CPAP or BILEVEL follow-up titration

Home study sleep

Pediatric sleep study

Ordering Physicians Name:

Date Ordered:

Additional Information (if needed):