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Sleep Referral Form
Patient Name
*
First
Last
Sex
*
Male
Female
Age
*
DOB
*
Date Format: MM slash DD slash YYYY
Date
*
Date Format: MM slash DD slash YYYY
Referring Physician
*
Family Physician (PCP)
My Main Sleep Complaint(s) Is:
Main Sleep Complaint
*
Breathing
Breathing
Snoring
Breathing
Witnessed Apneas
Breathing
Awakenings gasping for air
Breathing
Awakenings with a dry mouth
Breathing
Morning headache
Breathing
Frequent urination at night
Breathing
Snoring is worse on my back
Breathing
Snoring is worse after alcohol
Breathing
At night my heart beats rapidly
Daytime Functioning
Daytime Functioning
Excessive daytime sleepiness
Daytime Functioning
Low mood and/or irritability
Daytime Functioning
Memory impairment
Daytime Functioning
Difficulties with concentration or attention
Daytime Functioning
I have had injuries as the result of sleep
Daytime Functioning
I have slept for several days at a time
Daytime Functioning
Trouble doing my job because of sleepiness
Daytime Functioning
I had MVA due to sleepiness
Sleep Habits
Sleep Habits
I usually watch TV/read in bed prior to sleep
Sleep Habits
I often travel across 2 or more timezones
Sleep Habits
I drink alcohol prior to bedtime
Sleep Habits
I smoke at bedtime or upon awakenings at night
Sleep Habits
I eat a snack at bedtime
Sleep Habits
I sweat a great deal during sleep
Sleep Habits
I am unable to return to sleep easily if I wake up
Sleep Habits
I wake from sleep to go to the bathroom
Sleep Habits
I cannot sleep on my back
Sleep Habits
I eat if I wake up during the night
Insomnia
Insomnia
Difficulty with sleep onset
Insomnia
Frequent prolonged awakenings
Insomnia
Early morning awakenings
Insomnia
Thoughts race through my mind
Insomnia
Unable to sleep at all for several days
Restlessness
Restlessness
Involuntary limb movements
Restlessness
Unpleasant sensation in legs
Restlessness
Creepy-crawly feelings, aching in legs
Restlessness
Irresistible urge to move legs at rest
Restlessness
Grinding teeth in sleep
Mood
Mood
Being hospitalized for a psychiatric illness
Mood
My sleep is disturbed by sadness or depression
Mood
My interest in sex is less than what it used to be
Mood
I am unhappy about loving relationships in my life
Mood
I have considered or attemted suicide
Sleep Environment
Is your bedroom quiet?
is your bedroom quiet?
Yes
is your bedroom quiet?
No
Is your bedroom dark?
is your bedroom dark?
Yes
is your bedroom dark?
No
Is your bedroom temperature controlled?
is your bedroom temperature controlled?
Yes
is your bedroom temperature controlled?
No
Do you have a comfortable mattress?
comfortable mattress
Yes
comfortable mattress
No
Does your pet sleep in your bed?
pet sleep in bed
Yes
pet sleep in bed
No
Are you bothered by your bed partner snoring or movements?
partner snoring
Yes
partner snoring
No
Unwanted Events/Behavior
Unwanted Events/Behavior
Night Terrors
Unwanted Events/Behavior
Nightmares
Unwanted Events/Behavior
Sleepwalking
Unwanted Events/Behavior
Talking
Unwanted Events/Behavior
I have had sudden muscle weakness in response to emotions such as laughter, anger, or surprise
Unwanted Events/Behavior
I get "weak knees" when I laugh
Unwanted Events/Behavior
I often am unable to move (paralyzed) when I am waking up in the morning
Unwanted Events/Behavior
I often am unable to move (paralyzed) after a nap
Unwanted Events/Behavior
I often am unable to move (paralyzed) when falling asleep
Unwanted Events/Behavior
I have had hallucinations or dreamlike images or sounds when falling asleep
Unwanted Events/Behavior
I have had hallucinations or dreamlike images or sounds when falling asleep
Unwanted Events/Behavior
I have had hallucinations or dreamlike images or sounds when waking up
Unwanted Events/Behavior
I have had hallucinations or dreamlike images or sounds after a nap
Unwanted Events/Behavior
Sometimes I realize I have driven my car to the wrong place, and I can’t remember how I did it
Unwanted Events/Behavior
"Acting out my dreams" or behaving violently in sleep
Unwanted Events/Behavior
Other
Please Explain
*
Epworth Sleepiness Scale
How likely are you going to doze off or fall asleep in the following situations? Rate each description according to your normal way of life in recent time. Use the following scale (0= would never doze; 1= slight chance of dozing; 2= moderate chance; 3= high chance of dozing)
Situation
Chance of Dozing
Sitting and Reading
sitting and reading
*
Please enter a number from
0
to
3
.
Watching TV
watching tv
*
Please enter a number from
0
to
3
.
Sitting inactive in a public place (e.g.. a theater or meeting)
Sitting inactive in a public place (e.g.. a theater or mee
*
Please enter a number from
0
to
3
.
Sitting as a passenger in a car, for an hour without a break
Sitting as a passenger in a car, for an hour without a b
*
Please enter a number from
0
to
3
.
Lying down to rest in the afternoon when your schedule permits it
Lying down to rest in the afternoon when your schedule permits it
Please enter a number from
0
to
3
.
Sitting and talking to someone
Sitting and talking to s
*
Please enter a number from
0
to
3
.
Sitting quietly after a lunch without alcohol
Sitting quietly after a lunch without a
*
Please enter a number from
0
to
3
.
Sitting in a car, while stopped for a few minutes in the traffic
Sitting in a car, while stopped for a few minutes in the traffic
*
Please enter a number from
0
to
3
.
Sleep Pattern
Work Days (Weekday)
Off Days (Weekends)
Typical Bedtime:
typical bedtime
typical bedtime
AM
PM
typical bedtime
typical bedtime
AM
PM
Typical amount of time it takes to fall asleep:
Typical amount of time it takes to fall as
Typical amount of time it takes to fall as
Typical number of awakenings per night:
Typical number of awakenings per ni
Typical number of awakenings per ni
Activities that you normally do during nighttime awakening(s):
Activities that you normally do during nighttime
Activities that you normally do during nighttime
Typical amount of time to fall back asleep:
Typical amount of time to fall back aslee
Typical amount of time to fall back aslee
Typical Wake Up Time:
Typical Wake Up Time
Typical Wake Up Time
AM
PM
Typical Wake Up Time
Typical Wake Up Time
AM
PM
Desired wake up time:
Desired wake up time
Desired wake up time
AM
PM
Desired wake up time
Desired wake up time
AM
PM
How do you usually awaken, i.e., alarm clock?:
How do you usually awaken, i.e., alarm
How do you usually awaken, i.e., alarm
Typical time you get out of bed:
Typical time you get out of b
Untitled
AM
PM
Typical time you get out of b
Untitled
AM
PM
Total amount of sleep per night:
mount of sleep per ni
mount of sleep per ni
Number and timing of daytime naps:
er and timing of daytime naps
er and timing of daytime naps
Habits
I drink caffeinated beverages during the day
I drink caffeinated beverages during the day
cups/bottles/cans per day
*
Please enter a number less than or equal to
3
.
cups/bottles/cans per day
Do you smoke?
do you smoke?
Yes
do you smoke?
No
What
Amount per Day
For How Many Years?
Cigaretts
Cigarettes
cigarettes
pack(s)
cigarettes
years
cigar(s)
cigars
years
tobacco
Tobacco
tobacco
pipe(s)
tobacco
years
Do you drink alcohol?
Do you drink alcohol?
Yes
Do you drink alcohol?
No
What
Frequency
Amount Per Week
Beer
Beer
beer
Daily
Weekends
Rare
beer
cans/week
Wine
Wine
wine
Daily
Weekends
Rare
wine
glasses/week
Liquor
Liquor
Liquor
Daily
Weekends
Rare
Liquor
shots/week
Do you exercise?
exercise
Yes
exercise
No
Frequency
times/week
Duration
minutes
Are you on a diet?
are you on a diet?
Yes
are you on a diet?
No
Social History
Marital Status:
marital status
Single
marital status
Married
marital status
Divorced
marital status
Widowed
marital status
Sleep Alone
marital status
Share a Bed with Someone
marital status
Share a bedroom, but have separate beds
marital status
Share a dwelling, but have separate bedrooms
Number of Children
Ages of Children
Employment Status:
employment status
Employed
employment status
Unemployed
employment status
Retired
employment status
I am currently a student
employment status
My job requires driving a vehicle
employment status
I work with dangerous equipment or substances
employment status
I am a shift worker on rotating shifts
employment status
I am a permanent or long-term, third-shift worker
Review of Systems
Review of Systems
Frequent Headaches
Review of Systems
Fainting or Passing Out
Review of Systems
Sudden loss of vision or strength
Review of Systems
Inability to Speak
Review of Systems
Hearing loss or ringing in ear(s)
Review of Systems
Hoarseness 2-4 weeks
Review of Systems
Nosebleeds
Review of Systems
Cough for more than 2-4 weeks
Review of Systems
Coughing up Blood
Review of Systems
Shortness of Breath or Wheezing
Review of Systems
Swelling in Feet or Ankles
Review of Systems
Chest Pain, Tightness or Pressure
Review of Systems
Irregular or Sudden, Fast Heartbeat
Review of Systems
Difficulty Swallowing or Food "Sticking"
Review of Systems
Frequent Heartburn/Indigestion
Review of Systems
Abdominal Pain
Review of Systems
Frequent Constipation
Review of Systems
Frequent Diarrhea
Review of Systems
Rectal Bleeding/Black Stools
Review of Systems
Difficulty Urinating/Incontinence
Review of Systems
Blood in Urine
Review of Systems
Urinating more than 2 times per night
Review of Systems
Pain in joints or bones
Review of Systems
Unusual bruising or bleeding
Review of Systems
Epilepsy/Seizures
Review of Systems
Change in wart, mole or skin growth
Review of Systems
Weight loss of more than 5-10lbs
Past Medical History
Past medical history
Hypertension (high blood pressure)
Past medical history
Diabetes
Past medical history
Lung problems/COPD/asthma
Past medical history
TIA "Light Stroke"
Past medical history
Seizures
Past medical history
Back or joint problems (arthritis)
Past medical history
Cancer
Past medical history
Thyroid problems
Past medical history
Heart Disease
Past medical history
Depression
Past medical history
Reflux
Past medical history
Stroke
Past medical history
Hepatitis/jaundice
Past medical history
Anxiety
Past medical history
Fibromyalgia
Past medical history
Blackouts
Past medical history
Hearing Impairment
Past medical history
Stomach or colon problems
Past medical history
Chemical dependency or abuse
Past medical history
Alcoholism
Female
Past medical history
Premenstrual syndrome
Past medical history
Menopause
Male
Past medical history
Prostate problems
Past medical history
Erectile dysfunction/impotence
List Other Past Medical Problems and Dates:
Untitled
List Surgeries and the Year
Untitled
Current Medications
Medication
Dose
Times per Day
medication
dose
times per day
medication
dose
times per day
medication
dose
times per day
Allergies
Untitled
Past Sleep Evaluation and Treatment
past sleep evaluation
I have had a previous sleep disorder evaluation
past sleep evaluation
I have had a previous overnight sleep study
past sleep evaluation
I have been prescribed a CPAP or bilevel PAP machine for home use
past sleep evaluation
I have previously been prescribed medication for a sleep disorder
past sleep evaluation
I have previously been treated for a sleep disorder
past sleep evaluation
I have had a daytime nap study
past sleep evaluation
I have had surgical treatment for a sleep disorder
Family History
Has an immediate blood relative had any of the following?
Family History
Cancer
Family History
Diabetes
Family History
Hypertension
Family History
Heart Disease
Family History
Thyroid Disease
Family History
Stroke
Family History
Anxiety/Depression
Family History
Sleep Apnea
Family History
Narcolepsy
Family History
Other
Other
*
Vital Statistics
Height (feet)
*
Height (inches)
*
Weight (lbs)
*
Neck Size
*
What was your weight one year ago? (lbs)
What was your weight five years ago? (lbs)
Any additional information you want to provide for the physician
Comments
This field is for validation purposes and should be left unchanged.
