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ADDITIONAL INFORMATION
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(718) 684-6393
Request for Polysomnography
PATIENT INFORMATION:
Sex
M
F
Please submit a photocopy of the patient’s insurance card (FRONT AND BACK)
TEST REQUESTED: (Check Applicable)
Please schedule a consultation with a Sleep Specialist
Full service polysomnography (PSG), if positive CPAP/Bi-PAP/ASV Titration
Dental Sleep Medicine Evaluation/Oral Appliance Therapy
Split-night polysomnography (at least 2 hrs. of diagnostic study followed by CPAP/BiPAP Titration if needed)
Multiple Sleep Latency Test (MSLT) or Maintenance of Wakefulness test (MWT)
Home Study
Consultation with Behavioral Sleep Medicine Specialist (For Insomnia)
CPAP Center- EVALUATION (CPAP Machine order/supplies/mask fitting/maintenance)
Indications: (Check Applicable)
Obstructive Sleep Apnea
Parasomnia
Physiological insomnia
Neurologic problem/Autism
Circadian Rhythm Disorder
Central Sleep Apnea
RLS/PLMD
Pre/Post Surgery
Narcolepsy
Other :
Symptoms:
Daytime Sleepiness
Shortness of Breath
Obesity
Witnesses Apneas
Choking during Sleep
Arrhythmia
HTN
GERD
Dyslipidemia
Diabetes
Non-restorative sleep
MEDICAL HISTORY: (Faxed history and physical preferred)
Asthma
Emphysema
Seizures
Ischemic heart disease
Diabetes
Stroke
Large tonsils
Nasal obstruction
Enlarged tongue
Psychiatric Disorder
Hypertension
Claustrophobia
Other :
NEUROLOGY
Dental / Oral Appliance
Custom Fabricated Oral Appliance
EMG / NCV
EEG
VNG
VEEG
72 HOURS
48 HOURS
24 HOURS
REFERRING PHYSICIAN
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